[00:00:00] Kara: Sick of the fatigue and fog? Fed up with the unpredictable flares? Hangry from the super restrictive diets?
Hello, and welcome to the Crunchy Allergist Podcast, a podcast empowering those who like me, appreciate both a naturally minded and scientifically grounded approach to health and healing.
Hi, I'm your host, Dr. Kara Wada, quadruple board certified pediatric and adult allergy immunology and lifestyle medicine, physician Sjogren's patient and life coach. My recipe for success combines, the anti-inflammatory lifestyle, trusting therapeutic relationships, modern medicine, and mindset to harness our body's ability to heal.
Now although I might be a physician I'm not your physician And this podcast is for educational purposes only.
[00:00:50] Kara Wada: Welcome everyone. I am so excited to welcome everyone back to the crunchy allergists podcast. Today, we have an incredible. Guest with us. It is Dr. Sarah Boyles. She is an expert Urogynecologist, and we will talk all about what that means, but she has over 15 years of clinical experience, she manages her very successful group practice out on the west coast, publishes widely in her field and creates national quality standards for her area of medicine.
She really helped people recognize the need for pelvic floor education and society, and has recently pivoted to creating quality content for women. That's easy to obtain outside of that clinic space. You can see her work at the thewomensbladderdoctor.com and on Instagram @thewomensbladderdoctor. And we will link for those are two of those in the show notes.
So Dr. Sarah, can you explain to our listeners who are a combination of healthcare professionals and and people interested in misbehaving immune systems but what is a Urogynecologist?
[00:02:05] Dr. Sarah Boyles: Yeah. So I'm a urogynecologist is someone who only takes care of females.
And we really specialize in the female pelvis. So most practitioners who are urogynecologists, did a residency in obstetrics and gynecology, and then did a fellowship. You can also do urology and approach it. From that perspective but most of us did OB GYN first and it is a combination of surgery, but we also do a lot of medical management and procedures to basically help with everything in the female pelvis that nobody ever wants to talk about.
So incontinence, urinary incontinence, fecal incontinence, pro. There's definitely a good proportion of patients. I see that have pain or, maybe difficulty after radiation treatment. Just a whole gamut of different conditions that we see.
[00:03:00] Kara Wada: How did you find your way to that part of medicine?
[00:03:02] Dr. Sarah Boyles: For me, I think it's always interesting how, you make these decisions. I would tell you that I went into medical school thinking that I wanted to be a pediatrician and then quickly realized that while I really like kids, I don't like parents very much. And I say that as a parent and I was like, wow, I just, I can't imagine doing this.
And then I realized I have fixer personality. I like taking care of people for a finite amount of time and to help them through something and kind of fix it. I do see some patients over long periods of time, but a lot of it's pretty you come to with a problem, we fix it and then you hopefully move on and don't have any more issues.
My preferred population, the population that I really liked to care for is older women. And I have known that. I figured that out really early in medical school. And so I went to the university of Pittsburgh. They have a really small, strong you're going to college program there. And when I did my obstetrics and gynecology rotation, Realize that, and I thought, wow, this is really what I want to do.
But for me, you spend so much time in your practice and so much time with your patients. And I, I just love my patient population. There's so much fun to take care of. So that's how it happened. I thought about urology for a while. But didn't, I thought that residency would be less ideal for me.
So too much prostate exactly what was coming to mind.
[00:04:35] Kara Wada: I, I think when I hear and think of urogynecology, I'm always drawn back to memories of my dad's mom, my grandma, who was she's a hilarious woman grew up in kind of the the foothills of Appalachian. Did not have much of a filter. And so did not have, I think a lot of the concerns that most women have about talking about incontinence and incontinence issues.
And she dealt with a lot of issues after having three children, the last, which was my dad and I just, I don't have very many memories of her cause she passed away when I was in high school. But I do recall her sharing with me, like after you have babies or even before you have babies, you need to do your CA your Kegal exercises.
And so it was such a random thing for a grandpa to share.
[00:05:27] Dr. Sarah Boyles: But I would also say she was ahead of her time. Because most grandmas do not say that. Most people do not want to talk about these things. And so the fact that she knew that is pretty amazing. Yeah.
[00:05:39] Kara Wada: It especially, and I think back now, like in the context of it all.
Only had a high school diploma and, and from a more Southern upbringing, like all these different factors that really would potentially fall into more of, that is, we connected over this idea of invisible illness. So much of these conditions remain invisible.
Because we don't want to talk about that.
[00:06:03] Dr. Sarah Boyles: Yeah. Yeah. We say a lot that it's the last taboo in medicine, right? There was that period, not too long ago where women wouldn't talk about breast cancer and that has totally gone away. For the most part it's gone away. But yeah, incontinence people really don't like to talk about and it's such a common issue.
Nobody talks about it. Everyone thinks that they're the only person that has it. And it may seem like a small issue, but there are just so many things that kind of stem from that incontinence. It becomes a quality of life issue. People stop going out, they socially isolate, it leads to increase rates of depression.
And then if you're not going out and doing things, there are, physical ramifications that can come from that. It can interfere with relationship. Because it's hard to feel, vibrant and attractive when you're leaking. So it, from my perspective, people ask me all the time, why I do this.
And I'm like, wow, that's just really gross. I can't believe you do that. From my perspective it is such an amazing thing to be able to help women with this quality of life issue. And then have them. Go back to the things that they love, have them be more active and it, it quickly improves people's self-confidence too, right?
It can just, there's so many downstream effects from it that it's, it's an amazingly rewarding thing to participate in.
[00:07:31] Kara Wada: I don't doubt it, even from the little little hints of things I have experienced after the birth of my three children and dealing with some of the symptoms related to Sjogren's and dryness that, I distinctly recall talking with my OB GYN as a newlywed.
I wasn't diagnosed at the time and talking through some of those issues and I just think we remember being incredibly embarrassed to talk about dryness issues in my late twenties, early thirties,
[00:08:01] Dr. Sarah Boyles: It is hard to talk about your vagina, right? Yes. Those are very difficult words for women and, Depending on who you're talking to sometimes it's not received very well.
So there's a lot of literature about how women bring this up to physicians and physicians poo it. But a lot of that is because, women are embarrassed to bring it up. They bring it up as the physician is concluding the appointments. They're moving on. They know because they don't lead with it.
They create the impression that it's not an important problem. And then, because it's something that we don't talk about a lot, we don't really have a shared vocabulary. Nobody really talks about their pelvis. And so the words that women use to describe what's going on with them are not the words that we would use as clinicians.
I frequently think I should, keep a list of all the ways that people have described their vagina to me B because it's, it's amazing. And sometimes it takes awhile to make sure we're using the same words and we're talking about the same thing.
[00:09:01] Kara Wada: That's that's so true in that there are, there's just so many slang terms I could see where you almost need like an urban dictionary for it.
[00:09:14] Dr. Sarah Boyles: And I'll tell you that sometimes it's hard for me not to laugh. Sometimes I will giggle. And just be like, wow, that's a new one. I've never heard that one before. I, but. You know what I mean? My patients always know I'm not laughing at them. I just, I don't know.
It's just one more kind of interesting thing about this part of medicine. And, Rather than, being embarrassed about it or making someone feel embarrassed about it, I, I just find, the whole thing kind of comical, how uncomfortable we are with our own.
[00:09:47] Kara Wada: Yes. And I'm just thinking about the role that society plays in us becoming that way. I'm thinking about my little girls who will run around the house naked in, excited, no worries, no qualms or anything and how quickly that changes.
[00:10:06] Dr. Sarah Boyles: And, yeah. How quickly we become ashamed of our bodies and convinced that we don't have a perfect body.
And I think all of that is getting harder, with access to images of so many people who are photo-shopped and, don't necessarily have realistic bodies. Yeah, I know it's interesting when you have little girls, you look at them and you just think, wow, what are we doing to you?
How do we make this better?
[00:10:33] Kara Wada: Just had a conversation earlier today with my friend partner colleague about we were talking about the role of like how food plays into body image. And I was getting ready for vacation and thinking about how growing up seeing my mom diet so much before vacation so that she would look good in swimsuit pictures, like later on and how at nine years old, that I still am, I'm still am seeing that, feeling that and not wanting to, I want to be the change for my girls. But also my oldest is almost seven like I only have probably what, three or four years before, she goes and starts going through puberty, if that, and all those difficult conversations that are to come.
[00:11:17] Dr. Sarah Boyles: Yeah. Yeah.
[00:11:18] Kara Wada: Segwaying, but a similar topic was something that comes up pretty often. I think in media is this overwhelming concern that we need to do something special to clean our vaginal area, our vulva area to use the correct anatomical terms. Would you mind setting the record straight? I always love a good mythbuster.
[00:11:40] Dr. Sarah Boyles: Yeah. Yeah. So I would tell you that. So when I was in medical school, we worked with this amazing woman who has a PhD, whose name was Sharon Hellyer.
And she used to say that the vagina is like a self cleaning oven. You just leave it alone and it takes care of itself. And that is really true. You should not be putting anything inside the vagina. And then on the outside, just, various simple soap and water is the best way to go.
Any time you're introducing anything into the vagina or douching and this is, this is a cultural thing, right? It's really hard to talk women out of this when it's something they've been taught to do. You really disrupt the the microbiome.
And then you're much more likely to get bacterial vaginosis and other infections and irritation. A lot of times when we see people in the office who are having. Vulvar discomfort or pain or itching. A lot of times it is the things that they are applying to the vagina, or the vulva.
And stripping all of those things off and saying, okay, no, I just want you to use, the most basic so and water and nothing else. Don't put badges, fill don't put anything. Don't put anything that smells like pineapple. Then they do much better when you strip all of those things away.
But yeah, there's such a huge culture around that. And so yeah, so much media attention to that, which is just strange to me. I don't, I don't understand when that all came about.
[00:13:18] Kara Wada: I would say that's an area that. We don't have probably a whole lot that overlaps in our two areas of medicine, but that is definitely something that I occasionally we will hear about too, with rashes related to topical products or even the, like the wipes that are out there as well.
There are several preservatives and wipes that can be really bothersome.
[00:13:39] Dr. Sarah Boyles: One of the things that I tell people all the time, cause a lot of times we do have patients who are using a lot of whites, especially if they're leaking, cause then you get a, you can get a contact dermatitis from the urine and you're trying to put other products on and you can just make everything a lot worse, sometimes the best thing that I can say to someone is look, I want you to get a little water squirty bottle, and squirt yourself off with water, pat yourself, dry and don't do anything. Cause yeah, I agree with that. And people get baby wipes all the time thinking that baby wipes must be so delicate and they're not, it's terrible. They're terrible. Yeah.
[00:14:15] Kara Wada: We with Oliver, I, thought with the program finally and switched over to the WaterWipes, which are virtually, I think there's water and a tiny bit of like maybe citric acid or something. But we definitely have kept the little squeeze bottles that I got with from labor and delivery and they're in each bathroom just in case, we need anything. And. I was amazed.
It's been a few years now, but we visited my husband's family that still lives in Japan. And they have created a whole industry around the special toilet seats that will help clean things off. So maybe we need to take up.
[00:14:52] Dr. Sarah Boyles: Yeah. Get back to the days or something. Yeah. Yeah. But just the water is so much better.
[00:14:59] Kara Wada: I know one of the other things that we've talked some about are some of the structural and muscle type changes that occur in the pelvis over the course of the lifespan and in aspects of that, that come into your practice. So if you could share a little bit about those areas.
[00:15:19] Dr. Sarah Boyles: Yeah. I think one of the areas that You know we don't really, there are a lot of things, every specialty has their one thing I think that they think no one else pays attention to. And for us, it's really your pelvic floor muscles, right? So your pelvic floor muscles, right? Support all of the organs in your pelvis. They support the bladder, they suppose the vagina in women. So in men, you men still have a pelvic floor too.
And they support the anus and the rectum. And those muscles are attached to your sphincters, right? They provide support. They keep you dry. They're more likely to get damaged in women because the child. So you can have a direct muscle injury. You can also have nerve injuries that you may not realize at the time of delivery.
What can happen is those muscles can also have a lot of tension that men get irritated. And we see a lot of patients who have. Urinary frequency and urgency and pain with voiding who think they're getting chronic urinary tract infections, and it's really muscle pain that's causing it.
Your ability to differentiate between a bacterial etiology and a muscular etiology really does not exist. Patients who have pain with intercourse, which is also pressing on those muscles. If those muscles are irritated or even pain with bowel movements. I see a certain number of patients who have pain or have some of these issues. And it's related to the pelvic floor and the muscles. And that's something that, isn't often included in, a differential we just don't always think about it. And it's not always the whole answer, but it is frequently part of the answer. And I feel like over the last couple of years since the pandemic started pelvic floor kind of hypertonicity and pain has definitely, gotten worse. And I think some of that's because of anxiety and some of that's because of, ergonomics and how we're using our bodies or not using our bodies and working from home and not doing a lot. Yeah. We see that a lot more.
[00:17:24] Kara Wada: I think when you first shared that little nugget of knowledge with me about not being able to distinguish like that sensation between, a possible urine infection versus the muscle, like the muscle versus infection.
Cause was one of those, like the mindblowing emoji
[00:17:45] Dr. Sarah Boyles: That's my favorite emoji.
[00:17:49] Kara Wada: It was not on my differential whatsoever. I felt like I had a decent, non urologists, non gynecologists grasp on like interstitial cystitis and some other conditions that are not necessarily taught super well or discussed much in medical school, just through a rotation I had as a student, but the role of reoccurrent urinary tract infection that comes up is I'm talking with patients who have suspected immune deficiency issues.
And so it's really important for me as a clinician to have a good, broad differential of thinking about what are, is this true infection? Is it not? If it's not, what else could it be? And certainly no, to ask for help, quite obviously. That was really helpful,
[00:18:33] Dr. Sarah Boyles: Especially in those patients, where they're culture negative. And they just get there. They're always super frustrated with the system, right? Because they're convinced they have a UTI. It really feels like a UTI to them, but they're, re recurrently culture night. And I think also for those patients who do have a UTI, but then have ongoing pain for a while after they're treated sometimes that can be muscle pain on top of the UTI. So yeah.
[00:19:15] Kara Wada: In your field. Are there any other aspects that would be helpful to share with our group?
[00:19:22] Dr. Sarah Boyles: I can think of one of the recommendations that's come about is that all women should be asked about urinary incontinence. And I hesitate to say that out loud, because I think that there are jobs.
So many things on the primary care physicians plate and adding, one more thing. It just seems incredibly difficult. Especially since it's not always an easy conversation. But I would say, at least a third of women leak and it definitely gets older.
It definitely increases as you get older. The first treatment for almost all types of leaking is really physical therapy. And so if you have someone and they have leaking, then, you should feel comfortable sending them on to physical therapy, once you've ruled out a couple of other things.
So knowing the physical therapist in your area and who it, Pelvic floor physical therapy, I think is a great place for a lot of people to start. It doesn't work for everybody, right? Not everyone likes physical therapy. This is, an intimate type of physical therapy. And so some women, aren't comfortable doing it and won't doing it, won't do it.
And that's absolutely fine. But for most women they get a lot of benefit from it. Even if it isn't the final answer.
[00:20:41] Kara Wada: How could that look from a lay person? Like I have not personally experienced pelvic floor therapy, so
[00:20:51] Dr. Sarah Boyles: Yeah. So they, do you mean what did they do?
[00:20:55] Kara Wada: Yeah. What would like an initial assessment, maybe you look like for a patient?
[00:20:59] Dr. Sarah Boyles: Yeah. The benefits of physical therapy. So any pelvic floor, muscle strengthening program will help with incontinence and, there's more and more, that's being marketed directly to patients and peri trainers and vaginal weights. And all of that definitely helps. But the benefit of a physical therapist is that, they do a lot of coaching and educating as well. And so they usually start with having, you do a 24 hour voiding diary, where you're writing down what you're drinking and what you're emptying and when you're leaking. And that has been shown to be a really powerful tool, just, we do them in the office too. And, for a lot of my patients, when I have them do that, they come back and they know what the answer. They've figured it out, they can figure out what their triggers are and wow. I'm getting up three times at night because I'm drinking, four glasses of tea and all the things that you just don't realize until you write it down, I can see you laughing because yeah, I know I'm the same way.
I don't realize anything until I write it down.
[00:22:01] Kara Wada: It's this it's the same process too. That can be so powerful with figuring out like food and tolerance issues. It's kind of a. Frankly, it's a pain in the rear end to do, but the amount of data and knowledge, intimate knowledge about yourself that you gather from that exercise is incredibly empowering and really helpful.
[00:22:25] Dr. Sarah Boyles: It's huge. And a lot of this, I think. Most people know, if you drank a lot of coffee, you're going to have to go to the bathroom. And coffee is a big trigger for a lot of people, but there are a lot of other foods that can do it. So tomato based foods can do it. Citrus foods can do it.
Some people I, we have a lot of patients who just drink too much water. We live in this super hydrated. Society where everyone thinks they need to just be flooding their system. And sometimes the answer is no, really you need to stop. Or, someone's switched to carbonated water thinking that, carbonated water is so much healthier and that too can be a bladder you're a 10.
So they usually start with the 24 hour diary and going through all of the educational things to help women. And then they will Work on your pelvic floor strength. And so that comes down to Kegel exercises and increasing how long you can hold. They'll work on your core muscles too. And then they will also assess to see if there's anything else going on. So sometimes, your pelvic floor might not be working so well, but it's really triggered by a hip injury, that you have. And so figuring out what else they can do to help you with. With stress incontinence. A lot of it is doing what's called the knack, right? Where you contract your muscles before you do the activity, that's going to make you leak.
So they teach you how to do that. And then if it's more overactive bladder, they work on urge suppression with you. So if you squeeze your pelvic floor muscles, so overactive bladder. Because the bladder muscle is contracting when you don't want it to, and it is pushing the urine out. So your pelvic floor and your bladder work in concert, right to your pelvic floor squeezes and that sphincter squeezes closed and the bladder relaxes, and then you store urine, right?
And then the bladder squeezes, the pelvic floor contracts, if you're going to empty. So if you do a couple of squeezes that tells the bladder to stop contracting. It starts this reflex and then you should be able to make it to the bathroom. And that's called urge suppression. It's a super easy thing to say out loud.
It's a really hard thing to master and learn to do. And then, the best thing about going to physical therapy is that. You have a coach, right? You have someone to ask questions, somebody to change your program, some to work with you. They also do a certain amount of biofeedback, a lot of women can't contract their pelvic floor.
And so if they can hook you up so that you can see the muscle contract or here the muscle contract, then you can learn to do that better. And that's just another that's because of the way we're wired, it's just, it's a hard place to assess and feel right. So much different than moving your bicep muscle.
[00:25:14] Kara Wada: Absolutely. It's I think it all, a lot of what you were mentioning comes back to this overarching theme that we talk about a lot on the podcast. And then I just talk about a lot in general, which is this idea. Little aspects or or tools that we can add to our daily routine that really aren't necessarily like totally reinventing the wheel or like the sexiest new thing, but are incredibly powerful, incredibly helpful, sustainable and really proven tools that can make a world of difference in our quality of life.
[00:25:51] Dr. Sarah Boyles: So that's the interesting thing about. Physical therapy, right? Is that, you would think that physical therapy only works when you're actively doing the exercises. And that if you stopped doing the exercises that you become deconditioned, and then it all goes back to normal, but there's been a lot of research looking at that.
And, after going through physical therapy, a lot of women incorporate those exercises into their day-to-day life. Whether they realize it or not. And so the benefit is sustained, which is great.
[00:26:27] Kara Wada: There's some similar, this is my little niche of medicine, but some similar research with vocal therapy for paradoxical vocal cord dysfunction, and going through voice therapy, same idea that you recession, as little as three sessions and people will have meaningful lasting change in their symptoms.
[00:26:46] Dr. Sarah Boyles: Which is surprising, right? You wouldn't necessarily think that. But yeah, it's pretty amazing.
And then just, at the pelvic floor, the idea is that it's hard to get it, back into shape, but then maintaining it is much easier. And requires a lot less effort. So yeah.
[00:27:05] Kara Wada: It's always fun we can talk about areas of medicine where we're not necessarily just offering like another pill or another, quick fix something that is like a lasting, meaningful change.
[00:27:16] Dr. Sarah Boyles: Yeah, but I think, it's hard because the patient right. Has to buy in and has to be at a point in their life where they have have capacity to do those things. We see a certain number of, new moms who are having a lot of leaking and issues. And with the patients a lot of times, we're just trying to, I'm just trying to get them through to a point where they have capacity to handle it. Cause you're, you're in survival mode.
[00:27:50] Kara Wada: I just need some sleep, right? Yeah.
[00:27:52] Dr. Sarah Boyles: It's hard. I can't, I'm always amazed when I have, patients who have young babies, and are doing physical therapy and are, doing great. Like how are you doing that? Cause I don't think I could have done that. Yeah, for the right patient, it is great.
And I wish we, everybody would do that. It doesn't always work that way.
[00:28:10] Kara Wada: But we're sharing all this great information and hopefully that will continue this trickle effect and this trickles will turn into streams and rivers and.
[00:28:21] Dr. Sarah Boyles: Yeah, I totally agree. And. It's always important for women to know that there are things that they can do.
A lot of women think that incontinence just comes with aging and it's just what happens and you just have to accept it. And that's definitely not the case. And there are a lot of just small little lifestyle modifications that can make a huge difference. So even with. Weight gain makes incontinence worse too. And there've been some studies to show that even, five to eight pounds can make a big difference in terms of leaking.
[00:28:54] Kara Wada: So it's not necessarily needing to make huge chips
[00:29:00] Dr. Sarah Boyles: Little things, right? Little things. And that's, I think the answer almost always is little things right.
And moderation and eating a little bit better and a little bit more exercise. That is what it always comes down to.
[00:29:16] Kara Wada: That always doesn't always get the headlines.
[00:29:18] Dr. Sarah Boyles: No, definitely not in the headlines. It's definitely not sexy and glamorous. I don't know. Maybe we just need to say it in a different way, package it a little bit differently.
[00:29:27] Kara Wada: Maybe we can put some pineapple sense to it.
[00:29:32] Dr. Sarah Boyles: That's pretty funny.
[00:29:33] Kara Wada: Thank you so much, Dr. Boyles. I sincerely appreciate your time and your expertise and sharing all of this really vital information to our Crunchy Allergists community and really helping make this, making this invisible illness area, area of invisible illness, more visible.
[00:29:54] Dr. Sarah Boyles: Yeah. Thank you so much. And thanks for all the education that that you do right. And putting yourself out there. I've really enjoyed.
[00:30:01] Kara Wada: I, this has been great and I can't wait until we get to collaborate again.
[00:30:05] Dr. Sarah Boyles: Yeah, you too.
[00:30:10] Kara: Before I say goodbye this week. I want to share how my partner, Jen and I are making sustainable the new sexy today. We're launching our new eight week program named air squared. Anti-inflammatory living redefined auto-immunity re-imagined air squared is the program I dreamed of finding when I was scouring the internet for help. After my diagnosis with Sjogren's. Imagine the amazing feeling of comfort in your own skin. More mental space to enjoy your life. Thinking about what you'll achieve when the constant brain chatter around your health and food is gone. It's time for a program that skips the long line of supplements and focuses on your long-term success. So if you are struggling to stay afloat amid the unrelenting fatigue.
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If you're keen to learn more about how to manage your misbehaving immune system with a naturally minded and scientifically grounded approach you can head over to www.crunchyallergist.com. There you can find my five foods you don't need to fear if you have sjogren's, join our email newsletter list, as well as checking out links and resources available in the show notes.
That's all for this episode folks See you again this time next week take care
