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Exercise During Pregnancy

April 10, 2020
exercise pregnancy naturopathic doctor toronto

Now that you’re pregnant, you’re probably wondering about exercise during pregnancy. I’m summarizing the Canadian guidelines for physical activity throughout pregnancy set by the SOGC.

By exercising during pregnancy, you’re positively affecting your and your baby’s health. If you don’t have any contraindications to pregnancy (which are posted below), now is the time to start doing something. Especially if you were previously inactive and/or considered overweight or obese.

How much and what type?

Ideally you should aim for about 150 mins of moderate-intensity activity over the week (think: 30 minutes, 5 days a week).

If you’ve been previously inactive, you may want to begin gradually at a lower intensity, and increase the duration and intensity as your body gets used to it.

Aerobic and resistance training, with a pinch of yoga are great options. And in terms of improving health outcomes for you and your baby, you should aim to do all of them within the week.

Some activities do carry a higher risk and are considered contraindicated during pregnancy – like scuba diving, any activities with physical contact, danger of falling, and non-stationary cycling. Avoiding high-heat activities like hot yoga – as it may cause dehydration.

What the F is DRA?

DRA, known as diastasis rectus abdominus, may occur in some people. Essentially, your abdominal muscles may begin to separate. If you’re noticing that this has happened, book a visit with your pelvic floor physiotherapist to see what you can do. This means that you may also want to avoid ab strengthening exercises for the time being.

One of my colleagues filmed a video about DRA a few years ago. Check it out if you’d like more info

What about the first trimester?

Studies show that exercise in the first trimester doesn’t increase the odds of miscarriage or congenital anomalies. In fact, not exercising during the first trimester increased the odds of pregnancy complications like gestational diabetes, gestational hypertension, excessive gestational weight gain and depressive symptoms.

Let’s keep it real though, most people are exhausted in their first trimester – so the idea of anything besides walking is absolutely not appealing. But, if your energy hasn’t taken a nose dive, or if you’ve reached the point in your second trimester where you feel like you can start your routine again – let’s get to it!

Should ALL pregnant people exercise?

Exercising during pregnancy can provide many health benefits, but there are women who shouldn’t engage in strenuous exercise as its contraindicated. Keep in mind, this doesn’t mean they’re not allowed to move and continue their activities of daily living.

Absolute contraindications to exercise include:

  • Ruptured membranes
  • Premature labour
  • Unexplained or persistent vaginal bleeding
  • Placenta previa after 28 weeks
  • Preeclampsia
  • Incompetent cervix
  • Intrauterine growth restriction
  • High-order multiple pregnancy – like triplets
  • Uncontrolled type 1 diabetes
  • Uncontrolled hypertension
  • Uncontrolled thyroid disease
  • Other serious cardiovascular, respiratory or systemic disorder

Relative contraindications to exercise include:

  • Recurrent pregnancy loss
  • Gestational hypertension
  • A history of spontaneous preterm birth
  • Mild/moderate cardiovascular or respiratory disease
  • Symptomatic anemia
  • Malnutrition
  • Eating disorder
  • Twin pregnancy after week 28
  • Other significant medical conditions

Obviously, if you fall into any of these categories you’ll want to check in with your OB/Gyn or Midwife to see about your specific health situation – especially if you fall into the ‘relative’ category. You’ll want to figure out the advantages and disadvantages of exercise with your care provider before you start to exercise.

Tell me about KEGELS

During pregnancy, you may start noticing some urinary incontinence – perhaps some leaking will occur when you’re running, jumping, and laughing. Although this is common, it’s not considered normal. Many books or other professionals will tell you to start doing kegels. Do NOT do this. Instead, visit a pelvic floor physiotherapist so they can assess your pelvic floor. The reason being is that your pelvic floor may be “tight” yet weak (hence the leaking), and doing kegels can cause your pelvic floor to become tighter, not stronger. However, sometimes kegels can be helpful – but it’s super important to get a professional assessment before starting these.

Never heard of kegels before? Check out this video filmed by one of my colleagues!

Final Thoughts

Exercise during pregnancy is a great thing if you don’t have any of the above absolute/relative contraindications – but always speak to your care provider if you have any questions.

If you’ve been a bit sedentary in the first trimester (that’s okay, pregnancy is tiring!), start slow with low intensity and shorter durations and increase as you go.

If you happen to notice any abdominal separation or even leaking while jumping/running/laughing, be sure to book an appointment with a pelvic floor physiotherapist. I’m writing this post during the COVID-19 pandemic and a lot of health care practitioners have transitioned to virtual visits, so there’s still an opportunity to see a pelvic floor physiotherapist or naturopathic doctor if you have the ability to do so.

References

Mottola, M., Davenport, M., Ruchat, S., Davies, G., Poitras, V., & Gray, C. et al. (2018). No. 367-2019 Canadian Guideline for Physical Activity throughout Pregnancy. Journal Of Obstetrics And Gynaecology Canada40(11), 1528-1537. doi: 10.1016/j.jogc.2018.07.001

Will it actually get better with time? Talking about dyspareunia, vaginismus and vulvodynia

October 15, 2018
dyspareunia, vulvodynia, vaginismus, toronto naturopathi, naturopathic doctor toronto

“The pain will go away once you’ve had sex a few times. You’ll get used to it. “ Have you heard this before? Sex shouldn’t hurt. Putting a tampon in shouldn’t hurt. Yet, for some women they experience painful sex. 

Because there are a few reasons why sex can be painful, I’m breaking down the difference between dyspareunia, vaginismus and vulvodynia. 

Dyspareunia

Dyspareunia, the fancy word for painful sex, is essentially not a condition, per se, it’s a symptom. It can happen with vaginismus or vulvodynia, but is not a condition like they are. 


Painful sex can happen before, during, or after. It might be there when sex happens for the first time and every time after (primary dyspareunia) or it can happen after a period of painless sex (secondary dyspareunia). 

When compared to vaginismus, women who experience dyspareunia have less sexual desire, lubrication, and penetration-related painful thoughts. 

In terms of treatment, it’s best to figure out the underlying reason of why the pain is happening.

Vaginismus

Do you ever feel like you’re hitting a wall, or there’s a sensation of no hole being down there? That might be because of vaginismus.

It’s an involuntary muscle spasm of the pelvic floor (the set of muscles holding up your lower organs), incredibly tense pelvic floor muscles (it’s like doing a bicep curl but never relaxing), impossibility of penetration, or fear of pain. The spasm can be felt at the opening of the vaginal canal. 

Because it’s a penetration disorder, you may experience pain with fingers, tampons, vaginal dilators, pap exams and sex. Although it happens with penetration, it’s a physical AND an emotional disorder. 

There are two types of vaginismus:

  • Situational vaginismus: sex might be a no-go, but inserting a tampon or finger doesn’t hurt. 

  • Spasmodic vaginismus: When the vagina spasms with penetration. 

It’s considered primary vaginismus when there has always been pain with sex, and secondary vaginismus when there has previously been painless sex. 

Vaginismus may happen because of past sexual trauma, strict sexual or religious upbringing, fear of first-time sex (pain, bleeding, tearing, ripping, penis too large, vagina too small, sexually transmitted diseases, fear of pregnancy) or fear of pap exams.   

Treatment usually involves a pelvic floor physiotherapy – dilators, biofeedback, and counseling with a sex therapist (which includes mindfulness, cognitive behavioural therapy and pyschotherapy).

vulvodynia, vaginismus, dyspareunia, vulva, toronto naturopath, naturopathic doctor, painful sex

Vulvodynia

Vulvodynia (aka. vulvovestribular syndrome or vestibulodynia) is a chronic pain condition where there is vulvar inflammation and pain in the vulvar area. 

There’s no know cause of vulvodynia, so a bunch of conditions need to be ruled out before it’s diagnosed. The pain also needs to be there for at least 3 months for it to be vulvodynia. 

There are a couple types of vulvodynia:

  • Localized vulvodynia: pain in a distinct part of the vulva (ie. the vestibule)

  • Generalized vulvodynia: pain affecting the entire vulva

Pain can happen because:

  • Provoked vulvodynia: pain happens with touch (sexual or not sexual)

  • Unprovoked vulvodynia: pain happens without touch

Treatment usually involves a pelvic floor physiotherapist for muscle work, a sex therapist for counselling (like CBT), acupuncture with an acupuncturist or naturopathic doctor, or helping restore the vaginal microbiome, promoting healthy hormones and rebalancing the stress response with a naturopathic doctor. 

Final Thoughts

Sex shouldn’t be painful. And if it’s something that you’re experiencing, it’s important to figure out why it’s happening. Don’t listen to people when they say “Can you just relax” or “Just tell yourself that sex won’t hurt.”

What you’re feeling is real. Your experience is real. There are health professionals that can help you have pain-free sex. If you need any recommendations in the Toronto area, please let me know. 

If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!

References

Simonelli, C., Eleuteri, S., Petruccelli, F. and Rossi, R. (2014). Female sexual pain disorders. Current Opinion in Psychiatry, 27(6), pp.406-412.

Pacik, P. (2014). Understanding and treating vaginismus: a multimodal approach. International Urogynecology Journal, 25(12), pp.1613-1620.

Why does it hurt to insert a tampon? It might be vulvodynia.

vulvodynia, painful sex, toronto naturopath, naturopathic doctor toronto

Inserting a tampon shouldn’t make you cry, right? What about pleasuring yourself? (If you are crying, it shouldn’t be because of pain). Then why does this happen? 

Vulvodynia (aka. vulvovestribular syndrome or vestibulodynia) is a chronic pain condition where there is vulvar inflammation in the vulvar vestibule area. Symptoms include: burning pain, redness and/or edema. About 20-30% of women will experience this condition in their lifetime.  

This is a pretty complex condition, and I go into detail in the article below to give you all the background information you may possibly need. Before your eyes glaze over, I talk about who can help you with vulvodynia and what natural treatments look like towards the end of the article. 

How is vulvodynia diagnosed?

Because we don’t know why vulvodynia happens, it’s considered a diagnosis of exclusion. This basically means that other conditions need to be ruled out before vulvodynia can be diagnosed. Also, you need to experience this pain for at least 3 months in order for it to be vulvodynia. 

How is vulvodynia classified?

This is another condition that uses the primary/secondary classification. 

Primary vulvodynia

Pain that is felt at first vaginal intercourse or tampon use.  

Secondary vulvodynia

Pain that occurs after a period of pain-free sex. 

What are the types of vulvodynia?

Provoked Vulvodynia (PVD)

This happens with sexual or non-sexual (ex. tampon insertion or contact with clothing) touch. 

Localized

Burning pain is felt at the vestibule, by touch or penetration. You may also experience a sensation of tearing during sex.  

Unprovoked Vulvodynia

Generalized

Aching or burning pain is felt around the entire vulva. Pain may radiate to perineum, thighs, bum, or the lower abdomen. Sitting, walking or tight clothing may make the pain worse. 

Mixed 

A combination of provoked and unprovoked pain. 

Why does vulvodynia happen?

Bad news: we don’t know why vulvodynia happens. But, we’ve got our theories!

Pain Theories

Believe it or not, there are 3 types of pain. Before you feel like you’ve been transported back to science class, let’s briefly explain them: 

  • Nociceptive pain: When pain is sensed at the vulvar vestibule (like when you’re inserting a tampon), pain sensing nerve cells basically turn on, a signal is sent to the spinal cord which is then transmitted to the brain. 

  • Inflammatory pain: This type begins with a nociceptive pain (ex. tampon touching the vestibule), but if it’s prolonged then inflammation will occur. Inflammation is a release of inflammatory cells (cytokines, histamine, other cells you may have learned about in grade 10 bio). These cells will cause an increase in the blood vessels, leading to inflammatory cells seeping outside of the vessels (near muscles and fat) and causing swelling. The inflammatory cells can also turn on the pain cells around the site of the vestibule causing aching pain.   

  • Pathological pain: Structural damage to the nervous system or abnormal function of the nervous system. 

Anatomy

Tight muscles of the pelvic floor, may contribute to vulvodynia. Women with vulvodynia usually have tense pelvic floor muscles, they’re unable to relax them and the muscles may not be all that flexible. 

Any damages to the pudendal nerve (which innervates the vulva) may contribute to the pain, and might have happened during any surgeries (ex. C-sections) or prolonged child birth. 

vulvodynia, vaginismus, dyspareunia, vulva, toronto naturopath, naturopathic doctor, painful sex

Common triggers

Last up, any vaginal (yeast or BV) or urinary tract infections, herpes simplex, trauma (using tools during delivery, including an episiotomy), back or hip injuries, hormonal changes (using birth control or simply perimenopause), past medications (like fungal cream) may cause vulvodynia. 

Stress, anxiety, depression, pain-related fear, may also play a hand in this too. 

Who can help treat vulvodynia?

Aside from your medical doctor, ob/gyn, or urogynecologist – there are other health professionals to consider adding to your team!

Pelvic Floor Physiotherapists

Remember how we talked about a tight pelvic floor? Before you attempt kegels (note: please don’t do that), go see a pelvic floor physiotherapist first. They will be able to assess your muscle tone and provide you with the right exercises to do, to get the muscles functioning properly. Be forewarned that this often requires an internal exam using 1-2 fingers to get an idea of how your muscles are working. 

Sex Therapists

It comes as no surprise that vulvodynia may put a damper on your sex life! Seeing a sex therapist may help with any negative thoughts or emotional distress associated with this condition. Because trauma like sexual abuse or divorce are likely to contribute to vulvodynia, these would likely be addressed as well. 

Naturopathic Doctors

NDs, like me, take a look at the whole body to figure out what exactly is going on. Remember all those common triggers we mentioned? My goal is to figure out if any of those are in play, and if they are, I treat them. I might change up your diet, prescribe a few supplements, or do some acupuncture – but it’s only because I want to feel better (because inserting a tampon shouldn’t make you cry). 

Acupuncturists

In the next section I’ll talk about how acupuncture can be helpful when treating vulvodynia. But basically, an acupuncturist is able to look at your specific symptoms through a different lens to determine how it can be treated by Traditional Chinese Medicine. Prescribing herbs and doing acupuncture are their go-tos for treatment. 

How is vulvodynia treated naturally?

This is a tough one. None of my texts, especially the ones about women’s health mention vulvodynia. And, if you search Pubmed (the mecca of all scientific articles), very few appear. But that doesn’t mean all hope is lost!

Vaginal Infections

If infections are the culprit, then I’ll start my infections protocol. Basically, I’ll make sure your immune system is keeping the bad bugs at bay, and you’re vagina is full of good bacteria (don’t worry, this doesn’t involve yogurt tampons). 

In on study looking at the vaginal microbiome, they found that the concentration of fungi was higher than the beneficial Lactobacillus! Therefore, making sure you have a healthy bacterial balance is key. 

Stress

Although I might not be able to get rid of every single source of stress, I can help your body manage it better. Studies show that women with vulvodynia have a blunted cortisol response, meaning that your body may not be handing as stress as good as it can. Using particular vitamins and minerals, as well as herbs, we can work together to re-establish a healthy stress response. 

Hormonal Changes

I’ve talked about the pill at length on the blog, but let’s quickly talk about what it specifically does to vaginal tissue. When you take hormonal birth control, your estrogen levels (not the one provided by the pill) and total testosterone decreases. The pill can make the vulva more sensitive to muscle strain, increased pain, decreased lubrication, and increased dyspareunia. No bueno. 

What does this mean for you? Well, we want to support hormone production, re-establish healthy hormone patterns, and help you to effectively detox the pill (we don’t need fake estrogens hanging around in your body). 

Acupuncture

Few studies have been done looking at the effectiveness of acupuncture and vulvodynia. If you’ve never had acupuncture done before (run, don’t walk!), it has been shown to be an effective treatment for pain. It helps to balance the yin and yang within the body, as well as ensure that the vital energy, your Qi, is flowing without obstruction. Qi flows through the meridians of the body, where acupuncture needles are placed. 

In a study from 2015, acupuncture was done in women with vulvodynia. Results showed that vulvar pain and dyspareunia were significantly reduced, although there was no significant change sexual desire, sexual arousal, lubrication, ability to orgasm or sexual satisfaction. 

Final Notes

If you’ve made it to the end, thanks for sticking with me! As you can see, this is a pretty complex condition, and your healthcare team may need to be quite diverse. At the end of the day, our goal is to help you feel better. 

If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!

References

Thornton, A. and Drummond, C. (2015). Current concepts in vulvodynia with a focus on pathogenesis and pain mechanisms. Australasian Journal of Dermatology, 57(4), pp.253-263.

Pukall, C., Goldstein, A., Bergeron, S., Foster, D., Stein, A., Kellogg-Spadt, S. and Bachmann, G. (2016). Vulvodynia: Definition, Prevalence, Impact, and Pathophysiological Factors. The Journal of Sexual Medicine, 13(3), pp.291-304.

Vadala, M., Testa, C., Coda, L., Angioletti, S., Giuberti, R., Laurino, C. and Palmieri, B. (2018). Vulvovestibular Syndrome and Vaginal Microbiome: A Simple Evaluation. Journal of Clinical Medicine Research, 10(9), pp.688-692.

Schlaeger, J., Xu, N., Mejta, C., Park, C. and Wilkie, D. (2015). Acupuncture for the Treatment of Vulvodynia: A Randomized Wait-List Controlled Pilot Study. The Journal of Sexual Medicine, 12(4), pp.1019-1027.