70. Pessaries, Prolapse & Stress Incontinence with Cara McDougall
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A pessary is like a sports bra for your vagina! Surabhi interviews Cara McDougall, a pelvic health physiotherapist specializing in pessary assessment and fitting. We discuss how pessaries support people with pelvic organ prolapse and stress urinary incontinence, who makes an ideal candidate, and the success rate. We debunk common myths and release the stigma around pessary use (it’s been around forever and there is no shame in wanting or needing one!).
Specific Topics:
What is a Pessary? → 0:01:53
History of Pessaries (it started in ancient Egypt!) → 0:02:10
Helping Patients with Pessary Care → 0:03:32
Symptoms of Pelvic Organ Prolapse (POP) → 0:06:45
Who is the ideal candidate and ideal timing for Pessary Use? → 0:08:34
What are unsafe circumstances for Pessary Use? → 0:13:40
Common Myths about Pessaries → 0:15:00
Gaining relief of symptoms with a pessary → 0:17:25
Trial Pessary → 0:20:00
Sex & Pessary Use → 0:21:18
Periods & Pessary Use → 0:22:36
What are pessary fittings like? → 0:27:00
Pregnancy & Pessary Use → 0:35:20
Pessaries & Stress Urinary Incontinence (SUI) → 0:44:59
Today’s episode is sponsored by Embodia https://www.embodiaapp.com/ - use code momstrength to save $20 off your first month’s Tier 3 membership.
Important Links:
—Find Toronto Pessary Clinic on Instagram @torontopessaryclinic
—www.torontopessaryclinic.com www.saskatoonpessaryclinic.com
—Want pelvic floor strength? Join my BASE fitness membership!
—Read my Blog: All your Prolapse questions answered or Does my vagina need a pessary (sports bra)?
Connect with Surabhi:
Website: https://www.thepassionatephysio.ca
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Please note this episode actually starts at 01:51 (not 01:00) so the timestamps are off by 51 seconds. I apologize for the inconvenience.
Cara McDougall
Surabhi: [00:01:00] Hi everyone, and welcome back to another episode of Mom's Strength. I'm so excited to have on Cara McDougall today. She's a pelvic health physiotherapist who specializes in pessary assessment and fitting.
We met at a pelvic health course and I just loved her vibe, what she does and how she supports people in their pelvic health and in their lives. So welcome, Cara. I'm so happy to have you here.
Cara: Thank you. I'm super excited to be here.
Surabhi: So, can you tell me for everyone, what is a pessary, first and foremost?
Cara: Yeah. So a pessary is a removable device that goes inside the vaginal canal to help with two common pelvic health conditions, namely pelvic organ prox, and stress urinary incontinence. .
Surabhi: Awesome. And how, or have these things existed for a long time? Are they like a newer thing? Because we're hearing about them more and more and more recently, but how long have they existed for?
Cara: Yeah, so they have been around forever. , a really interesting fact [00:02:00] is there are actually depictions on ancient Egyptian drawings. Wow. So they certainly did not look like what they look like today. We have thankfully made some advancements, , but in the early stages there are reports documented, , , , sort of wads of cotton, , of half, , pomegranates used, all used internally.
So Cool. That to support our organs. Yeah. So nowadays they are almost exclusively, exclusively made of medical grade silicone. Okay. So
Surabhi: that helps with, I guess, no allergies or, you know, there's no latex or anything on it. . Exactly. That is so cool. That like this has been, or something like this has been around forever because I think that helps to destigmatize it a bit because anytime you talk to somebody about pessaries, they think it's like this, you know?
Mm-hmm. , they have these preconceived notions, but then when, if they find out like, actually these things have been around forever, yes. It might help them [00:03:00] feel like, oh, okay. Like women have been, or people with ves have been supported forever. Mm-hmm. , you know, this isn't a new thing. , So tell me about how you got into Pess re assessment and fitting, cuz you, I'm sure you started off in pelvic health and then kind of discovered your passion for this.
Cara: Yes, absolutely. So when I was working in a multidisciplinary pelvic health clinic, the women that I was seeing who needed or could benefit from a pessary. , had to go through a lengthy process. So what would happen is I would refer them back to their gp, who would then refer them onto a specialist that would either typically be a gynecologist or a neuro gynecologist.
And that process in Ontario at that time could take anywhere from nine to 12 or more months. Wow. And yeah, so, , there was certainly a barrier to access of care. , and I at that time had taken my pessaries three training, but had not implemented it into my practice. And I just thought, my goodness, we as Pelvic health [00:04:00] physiotherapists and I as an in individual could do much better at serving my clients and making care accessible.
So in 2018, I decided to, , really focus my practice on pessary assessment and fitting. , and that is when I. Opened up, , my little clinic, which is solely devoted to, , treatment, conservative treatment of pelvic organ prolapse and stress urinary incontinence with pelvic floor training, education and pessary refitting.
Surabhi: Awesome. So people aren't coming to you just for the pest refitting, it's more of that kind of that holistic conservative management.
Cara: Certainly always try to maintain a holistic, , lens as well. Yeah, absolutely. We unfortunately can't just put the pessary inside and forget, , good body mechanics and lifting mechanics and breathing,
Surabhi: right.
So yeah, it's like part of the puzzle, but it's not the solution on its own. , and I think it's an incredible, , it's not only does it make you more [00:05:00] accessible, but I think pelvic health, physical therapists are more. easy to talk to. There's less of that like feeling of I'm going to see this surgeon or this doctor who sometimes, you know, because of their schedules and how they're, they often work is you don't have the time to have these long discussions about your health history and you know how it's impacting your life.
So I've had clients who have been told by their doctors, you don't need it. That's for older women. You know, you don't, your prolapse isn't that bad. So you know, this isn't, you know, you don't even need physio. Right? Like there's, there's often these, , barriers because doctors themselves are sometimes not aware of how these can benefit.
So that's why I really wanted to have you on to kind of, so we can all understand and advocate for ourselves if. , we are in this situation where we need a pessary or of any of our listeners who are like, oh my gosh, I have pelvic organ prolapse. I have tried this, I've tried that, and I need, I need more.
Mm-hmm. . , so tell me about how it can [00:06:00] support somebody with pelvic organ prolapse or, and what is pelvic organ
Cara: prolapse? Yeah, so pelvic organ prolapse, first and foremost is descent of any of the pelvic organs. So that could include the urethra and the bladder could include the cervix and the uterus, and could include the, , rectum and the small intestine as well.
, and so common symptoms, if you are listening and wondering, oh my goodness, do I have this, common symptoms might include heaviness or pressure felt very vaginally or rectally, , bulging that you might notice when you're wiping or you're in the shower. , those are the most common. Sometimes people will experience some pain as well, sort of a dragging sensation in their low back, and that is due to suspensory ligaments that hold some of these organs in place, being on stretch, , sort of continuous or repeated stretch and strain.
, but pain isn't primarily the first, , symptom that one [00:07:00] will present with usually, it'll usually be heaviness, pressure or bulging vaginally. , and. in the beginning. Oftentimes these symptoms will worsen by end of the day. , so you are horizontal all through the night. You get up in the morning, you feel fantastic, then you have a super busy crazy date.
And by supper time or 7:00 PM you're starting to notice, oh yeah, I feel some heaviness or pressure. And then, , if things do progress, then that time of onset of symptoms may, , creep up a little bit earlier in Wednesday. So that's, those are some of the first, , symptoms that one might notice, , that sort of would clue you into, oh, should I check out a pelvic health physiotherapist?
, do I need some muscle training? Do I need to talk about constipation or proper lifting techniques? And would aary be useful for me?
Surabhi: And so when is the point? , like what is your ideal, like if you were to paint a picture of like, when is the ideal time to talk [00:08:00] about a pessary or, , is it immediately postpartum, you know, after those first few weeks or is it later on in recovery?
What would be a good scenario?
Cara: Yeah, great question. This is gonna differ a little bit from individual to individual and we actually don't have a hard and fast, , answer in the literature or the research either. So it's very much, , taking a look at the whole piece. How is a woman managing physically and mentally?
Let's, let's take the population of, , shortly after having given birth, whether that's. C-section, vaginal delivery, whatever it might be. , and a woman may feel like, oh, things don't, just don't feel quite the same down there. Might go to their six week follow up appointment, might be given as a diagnosis of a mild prolapse, let's say, and may go home and Google that and, mm-hmm.
Surabhi: see? Yep. That's a familiar story with myself,
Cara: for example. Okay. . Oh, darn. Yes. [00:09:00] Unfortunately, all too. . , and then they might get on some forums or some blogs or some, , social groups and people are talking about, oh, I was told not to lift anything and this mom has a brand new baby. She has to lift and carry and rock and push and pull.
And now she's really concerned. So not only is this a physical, , does she have physically uncomfortable symptoms, now she's mentally concerned and worried. , so in a case like that, I would say the sooner the better. We don't, , I, I do not insert a pessary sooner than the six week, , checkup. But, , my approach to pessaries has changed, , since sort of specializing in this area.
I used to think of it as a little bit more of a last resort. Mm-hmm. . Okay. We've done your six, or sorry, your three or six or whatever it might be, months or weeks of pelvic floor muscle training. And we've [00:10:00] made, , x percentage of gains, but we're still not at a hundred percent. Okay. Now let's, let's try a pessary.
I no longer think that that is serving our clients best. Yeah. , if we can do everything possible right off the bat, , talking about constipation, then all the other things that we talked about, pelvic floor, muscle training, and get a support in there right away so that a woman feels confident and competent in her daily activities of caring for babe or whatever that might look like then fabulous.
Why would we make her suffer for x number of months? , when we have the tools that are safe, , that won't hinder her own strengthening of her pelvic floor muscles. , there's no, there are so few risks of pessary use that now. My approach is I let my clients know all of the options right off the bat and we pick what's going to be best serving for them given their lifestyle and their goals and their concerns.
And that's
Surabhi: [00:11:00] interesting because it makes sense. Like you offer more support earlier on in a recovery. Like I often think about an A C L tear. You're not putting the brace on eight months later. You're putting it on at the beginning and then weaning off of that. Right. Or, you know, wearing it for sport. And it's so interesting how with pelvic floor, it's like, mm, I don't want, I don't wanna insert anything, but I'm like, but you're inserting an I U d or the nuva ring or other things up there.
So it's like, let's remove that feeling of shame associated with that.
Cara: Absolutely. I love. Yeah. Sorry. I love the brace analogy. It's right on.
Surabhi: Yeah. Yeah, it's it, when you were just saying, I was like, that makes total sense and offering who would be a good candidate for it. So would it be someone with a grade or stage one prolapse, right?
Who's, you know, maybe it's discovered on assessment, but they're not that symptomatic or someone with a stage two even who's not thought symptom symptomatic, or is it symptom dependent or stage dependent, or both?
Cara: Yeah. Great question. And again, there's not a super straightforward [00:12:00] answer here, but I'll talk to the whole picture here.
So I have successfully fitted people with all stages of prolapse. Okay. Right from the most mild all the way to the most severe, where some people would say, , nope, that's not pessary appropriate. You are, the only thing that could help is surgery. So the whole, the whole continuum. And that is one thing that I really, really would like our listeners to hear is that there is no stage where a pessary is not appropriate to try.
Amazing. I, yes. Cuz I in clinic see wonderful results all across the board.
Surabhi: Now some people almost feel like they have to be bad enough Yeah. For their doctors or their OBs or whoever to make that referral. Right. So can somebody come to you directly, pelvic health physios are direct access in Ontario anyways.
So can people just book in with you directly or do they need a referral from a doctor?
Cara: So, yeah, great question. So this does differ across our beautiful country of [00:13:00] Canada. But I'll speak a little bit to Ontario. In Ontario. Yes, we are direct, practitioners of course. However, for pessary fitting, we do require a doctor's letter on file stating a woman is safe to use a pessary.
Okay, now there are only a, there are a few instances where she would not be safe. I'll just list a couple contraindications to pessary use. Those could include profuse, diagno, un, I'm sorry, profuse vaginal bleeding of unknown origin. Active vaginal cancer, pregnancy. I'll come back to that one in just a moment. Pregnancy, endometriosis. Somebody who is known or has expressed that they will not be compliant with follow up and maintenance, we can speak to that later as well. So the large majority of women who are calling and booking an appointment are safe to use a pessary. Yeah, the large majority. But it is a requirement that we have that on file in Ontario.
Now, this is not true in other [00:14:00] provinces, such as BC for example. So if there are any practitioners listening, I just very much say check with your college and your jurisdiction to see what is mandated and regulated and required in your, wherever you are licensed to. So yeah, that's, that's one thing.
The other thing that you had mentioned, just a couple of times, and I don't wanna forget to mention this is this idea of, okay, who is this appropriate for any stage? Yes, absolutely. And let's go back to the age thing for just a moment, cuz that is so important. Yes. For some reason, particularly in Canada, we have this idea of, oh, well you have to be X number of years old before we will consider a pessary for you.
Oh my goodness. I've
Surabhi: literally had clients been told this, you're so young you don't need this. This is for older women. I'm like, Right.
Cara: What? No. Yes. I wish if I could wave my magic wand and get rid of that myth, I would so do so. , I, my youngest client, , [00:15:00] just in my ca practice has been 22. Not saying that I couldn't see somebody younger and my oldest was a hundred and a half, so.
Wow. That's incredible. Yeah, it's, it's the whole age span. And people sometimes will come as well and they'll say, I, I have these symptoms. I haven't even had a baby. And so that's another myth that I would like to bust. This does not only happen to those who have carried babies. And delivered any method.
, yeah, there are different factors that can lead to pelvic organ prolapse and or stress urinary incontinence. Some of those things can include chronic straining. So whether that's constipation or a chronic cough, there's can be a genetic component as well. So there's multiple different factors that could land a person, in this space of having these symptoms.
So yeah. So no matter the age, no matter if you've had any babies, a pessary, if you're having these symptoms, a pessary could be appropriate for you.
Surabhi: Very cool. And I love that you busted those [00:16:00] myths because I've had clients who are like, oh, I wanna have a C-section next time, so my prolapse doesn't get worse.
And, you know, you can have a prolapse regardless of birth method. Mm-hmm. and age or, , whatever issues and. , you know, part of it is as we age, things in our bodies change too. So some of that I love that we talked about in the pelvic health course, that part of like stage one is now being classified as normal.
You know, there is a bit of give to tissues when you push strain, cough, and we need to be mindful of the fact that what we see feel is not always what the person is feeling. You know, what symptoms they're actually feeling. Yes, absolutely. And like going back to, yeah, if the person comes to you and they're like, I'm symptomatic, I, I feel this, I feel limited.
They would be a good candidate to refer to someone like you.
When you see someone, let's say who's been experiencing symptoms for a longer time, [00:17:00] do you find that the use of the. What, what are you looking for in terms of it's success? Are you looking for immediate resolution of symptoms or improvement?
, how do you know whether it works?
Cara: Yeah. This is the beauty of pessary fitting. It's almost immediate in that amazing initial. Mm-hmm. It's, it's so rewarding for both me and the client. It's so, it's wonderful.
Surabhi: , you're like, yep, I'm a magician. I just Right. made that disappear. .
Cara: Yes. We all wanted to feel that upon graduation. This is one of the few areas we can
Surabhi: Now I know why you got into bed pessary fittings.
Cara: Exactly. , yeah, so in almost all cases, not all, but almost all cases, the patient will notice an immediate relief of whatever symptom they are experiencing, if the pessary is going to work well for them.
Mm-hmm. So, , and I'll break that down just a little bit. research says that approximately 80% of women will do well with a pessary. That's great. So I mean, it's, yeah, it's, [00:18:00] that's a, a large, that's a large, yeah, yeah, yeah. So it's not a hundred percent. I always let my clients know that usually in the first conversation of when they're booking the appointments that it doesn't work for everyone.
And we can speak to that a little bit in a moment, but the large majority it will be successful for, and you just, mentioned like, what, what is success? What does that look like? So if a woman has pressure heaviness or bulging in that initial appointment where they are assessed and fitted for a pessary, those symptoms should be relieved.
And maybe it's not a hundred percent, but they should be markedly relieved, upon. Insertion of that pessary. And as soon as I do have a pessary inserted, I have them come up into the clinic space and move around. So if they say, you know what? I only have symptoms, whatever it might be, leakage or heaviness, when I do 10 jumping jacks in a row, or when I run for 10 minutes or whatever it might be, as best as possible, I replicate those things in clinic.
What are the most [00:19:00] aggravating, symptomatic activities? Okay. Do them. We need a really clear before and after picture of what does my body feel like and what do my symptoms feel like without a peary? And then when we put a peary in, what do they feel like now? And it can be amazing when they say, oh my goodness, I have not jumped for the last 15 years of my life.
Wow. And now I feel like I can, and I'm not leaking, or I don't feel that pressure. So that's just, I mean that's amazing.
Surabhi: That's an incredible win because people often feel Like they have signed away. Like, I'm not gonna be able to run again or jump again or do, X, Y, and Z again.
And it's so rewarding to be able to feel like, oh, my body is capable! And it's empowering. And do you fit them with, do you have to fit that person specifically or do you have trial pessaries? Like how does it work if they're coming to you on day one in order to experience that?
Cara: Yeah, so we do have trial pessaries. Yes, there are many different shapes and sizes of pessaries out on the market. A quick [00:20:00] Google search will show all different shapes and sizes and different looking things. So based on many different factors, we'll, trial specific pessaries. Now, the factors that we might consider when choosing the best pessary for a woman would be, boney tissue, landmarks, soft tissue integrity, the kind of prolapse, the severity of prolapse, and then their goals. This is a huge thing. Do they just want a pessary that they can put in to go for a run three times a week? Do they want a pessary where they put it in in the morning, they take it out before they go to bed?
Do they want a pessary that can stay inside for a long time and they don't have to think about it or touch it? Are they, so
Surabhi: it stays in when they sleep and
Cara: mm. Oh, okay. That right? Yes. So currently we are the leaving some pessaries in, not all of them, but some for up to about three months. Wow. Yeah, so that can be really helpful.
Now an important consideration is if a woman is sexually active and what that [00:21:00] sexual activity looks like. So some of the pessaries can, , welcome penetration while the pey is inside and some pessaries have to be removed for any sort of pen, vaginal PE penetration. , so that's where lifestyle goals, what's gonna work for these women.
Comes into play. And unfortunately, I've sometimes had women come to me who are fitted elsewhere and they say, I have this pessary, it's working really well, but I can't have sex with it in, and that's a really important part of my relationship or my life, or Yeah. Whatever it might be. Yeah. And so that, that, , huge ad l important ad l has been taken away, , just what since, , PAER was inserted.
So, uh, in those cases we might have to look at, okay, can we get the same support or similar support with a different kind of ri or is it simply, and this is so empowering, this is where physios, uh, shine, I think is that, can I just teach you how to take that thing out and put it back in? , and we have the time and the space, , and [00:22:00] we're great educators.
So we have the time and space and education to give to our clients, and I think that is humongous and so empowering. , yeah. So
Surabhi: and where does it, because if you're saying they can take it out themselves, is it. , first of all, can you have your period with it on, with it in?
Cara: Yeah. Okay. Good question. , so yes, the majority, yes.
If a woman is menstruating, , I do want that pessary coming out every, every day. Yeah. Okay. So even if they have a pessary that could be left in for three months, I want, during her cycle, I want that pey out once a day at least. That will depend a little bit on how heavy her flow is as well, but she can leave it in during her cycle if she so desires.
Now, if she typically uses a deep, uh, cup or, , a tampon, only one thing can be in the vagina at once. Okay. So that's either the pey or the cup or the tampon or whatever it. So that is a choice that the [00:23:00] menstruating, uh, patients have to make. , but it is safe to use
Surabhi: it. Yes. Okay. That's good to know. And how far in does it go?
Cara: Yeah, that actually depends a little bit on the different styles. Uh, some sit actually quite high part of, so there's rings, for example. , some of them sit like right behind the cervix, so depending on where the cervix is sitting in the vaginal canal, and sometimes that can be several centimeters inside the canal.
, yeah, the, the back of the ring, I guess, sits behind the cervix. , a cube for example, sits just above the pelvic floor muscles, so it's not very far in at all, thank goodness, because it's tougher to get out when it sits really high in the canal. . Uh, so it does just depend on the style of pessary. I,
Surabhi: if anybody here has used the Nuva ring before, I think we can all like, remember that time when you're like, this went a little bit too far in and you're just like, you have the moment of panic where you're like, oh my gosh, is this gonna come out?
But it always does. Uh, and [00:24:00] so I think that's where, you know, the education on like, okay, here's how you relax your muscles. Here's how you can access this would be so key. So people remove that fear of like, I always need to go somewhere else to have this done because I'm sure people who are coming to see you cuz you're in Toronto, like people are probably coming from outside of Toronto to come see you.
Cara: Absolutely. Yes. Yes. We have many of our clients traveling far distances to come see us. Absolutely. So, yes, I always, my preference is always let me at least verbally explain how to remove and insert just in case you get into a situation you live seven hours away from me, . , so if you get into a situation where you need this thing out, you at least have a little bit of know-how and little bit of confidence of how to get it out or, or whatever it might be.
Surabhi: Yeah. And it seems like family doctors aren't always familiar with pessaries in the first place. So even if you went to your doctor, they might, I don't know if they'd be able to help because Yeah, yeah. It's, from what I've heard from my, my clients, [00:25:00] they don't. all know much about it.
Cara: You're exactly correct. Yeah, some will, but I would say in my experience, the majority, , just simply don't have the training or the experience in pess reuse.
Yeah,
Surabhi: yeah, absolutely. And that, you know, bef for someone who's listening who's like, but why not? Like, just remember that even as a physiotherapist, you don't have much training in pelvic health. That's a, you know, separate specialization. And then within that, there's even more specialization to get into pry fitting.
So it's not something that every physio knows or every doctor knows. And so it's one of those more specialized things that you really have to know where to look for support. And, , I'm so grateful that you're in our city, like offering this, because now I'm like, I've already referred a couple clients to you, and I'm like, this is great.
Sometimes there are ex, I don't know, your wait list is probably long too, but there are extremely long wait list to get to see a urogynecologist. And can you talk a little bit about, is it similar the way, the approach that you would use [00:26:00] to fitting or are there slight differences depending on, you know, what
Cara: approach you take?
Yeah, great question. , Couple things there. So sometimes women will come in and think, oh, maybe there's this scientific way to be measured, and then that will just sort of do some calculations and spit out, oh, this is the peary I should have. That's literally what I thought. .
Surabhi: Okay. Oh, I
Cara: wish, I wish, I wish,
Surabhi: ,
So that's, I thought there was like some device you put in there and it like, measures the pressure or something, and then it's like, boop, here's your, here's your size.
Cara: business idea. Business idea. No. . Yes. So that's no. So PA fitting is trial and error still. , it's a little bit of science, so it's a little bit of art.
Uh, there are certainly objective things that I, as the fitting practitioner look forward to ensure it's a good fit. , not too small, not too large, uh, sitting in the correct position, staying in place with move. So those are all things that I look for. However, that is very much [00:27:00] combined with the subjective experience of the, uh, individual in front of me.
Is it comfortable? Is it, , does it feel supportive? Does it feel like it's descending? , can a woman perceive it? Ideally the woman doesn't, or the individual doesn't even perceive the pessary at all. Uh, so that is ideal. Now, that's not every woman's experience. Sometimes, , it just takes a little while for the body to get used to the pessary.
I kind of liken it to, if I go to the optometrist and I get a new prescription, it takes my eyes just a little bit of time to adjust, uh, to that new prescription. Same sort of idea, uh, nine point. Outta 10 of my patients will, their body will just get used to that feeling and will no longer sort of send the signals to the brain of, there's something inside here.
, there are a handful of women that I have, uh, attempted to fit who just, their bodies just did not like the pessary and the body just never got used to the pessary. And that would be one of the times where that 20% that [00:28:00] isn't successfully fitted, that would be one of the reasons why. ,
Surabhi: but, and is it cause it makes them sore?
Like is it, what, what, what is it that they don't like about it? Is it the, like their pelvic floor sore using it or? Yeah. Yeah.
Cara: So some women just perceive it and then they think, oh, well, like I felt my prolapse before I came here to not feel it, and now I feel this thing, this PEs inside of me. Right. Right.
And so we're no further ahead. We haven't reached their goal. Right. Yeah. So that, uh, but I do find for those public health physios listening, if I. Person is experiencing pelvic pain, has trouble within accommodation, , has tender points. They, those need to be rectified before they're going to do well with the P three.
Mm. So, so it's other things like that. , yeah, no, that was a bit of a tangent. Sorry. .
Surabhi: I know we're talking about so many good things here. Now, there I am curious because if so, if you're fitting somebody and [00:29:00] Oh, yes. , we were talking about how you fit and what the differences are between Yeah. Fitting styles.
Yeah. Thank you .
Cara: Thank you. Thank you, . Okay. So whether a person sees myself or any other public health physio or a urogynecologist, the fitting, , piece is exactly the same. Okay. They don't have special machines. We don't have special machines. It's trial and error. , we insert one, oh, no, that's a little bit too small.
Remove that right away. Put the next size in. So that is going to be consistent across practitioners. Now, the, the thing that physios typically can offer, and why I think we're perfectly positioned for this, is we typically have a little bit more time. Mm-hmm. , I am very grateful that I live in Canada and I have access to our, , healthcare system.
Very grateful, but it's. overburdened at this time. It is,
Surabhi: yeah. Especially the past few years, it's just been, and so sometimes I like, you know, the high priority cases get seen, but then if you're [00:30:00] considered lower on the priority list, it's like, well, your life matters too, but you're just not as severe so you don't get seen.
Right,
Cara: exactly. Yes. Pelvic organ prolapse and stress urinary incontinence are not life-threatening. Yes. Therefore, in the queue, we'll always get bumped back. Right. Yeah. So what we can offer is I spend an hour with my patients in the beginning for that initial assessment to fit them. , I have yet to hear of other practitioners having an hour to assess and fit for a pessary.
Right. So, , what a patient can expect when they come to our clinic is, , that assessment and then we trial as many different pessaries as we need to to find that amazing aspect. Yeah. And then we have That sounds awesome. ,
Surabhi: which I'm just thinking like, I can't imagine going to a practitioner and being like 15, 20 minutes.
All right. Like let's, you know, like it's also a sensitive area so people need time to be like, okay, there's gonna be something going up my vagina a bunch of times. You know, and people [00:31:00] often attach a lot of emotions with their path, you know, with their prolapse in particular. So, , I love that they have that time and space to feel like comfortable to try a bunch of different ones.
And are they getting fitted right away? So they don't, it's not like eyeglasses where you're like, come back in three weeks, I'm gonna fit this, you know, make it for you so they get it right away.
Cara: Yeah, we try to be as efficient as possible, both with time and resources. So nine times outta 10, our, uh, patients go home that day with their pessary.
That's amazing. So, yeah, it is. It is. , and, and then they've had time to experiment with it in the clinic as well. Time to go to try to avoid their bladder and go on the treadmill like I was mentioning before. , we really try to give sort of the best snapshot in that one hour of how is this pessary going to perform and serve you in your real life, in activities of daily living.
So that's really our goal. , and [00:32:00] then we follow up with the women, of course, uh, little while later to make sure the pessary is doing what it should be doing. Uh, make sure that. There's no, , indications of any irritation of the vaginal mucosa. Uh, just troubleshoot any, any questions. Uh, practice inserting, removing again, if we need to do that.
Oh, and that's the other piece in that, uh, initial assessment, the education component. I know I've said that a couple times, but it's so huge. Sometimes people just need to sit down with the practitioner and say, what exactly is happening with my body? I got this diagnosis and I have no idea what this means.
And is it life-threatening? Mm-hmm. , I thought this was a tumor when I first saw this. Like, is this, is this cancerous? Cause it's turned into cancer, what is going on with my body? And so just to have that time and space to, , empower our patients with education is, is probably my favorite piece of everything actually.
Surabhi: I feel like it's one of, education is one of those things that clients aren't like, I'm booking this appointment with this person for [00:33:00] education, but that's often what they need the most. Right. And, you know, regardless of the type of physio you are, it's, you know, , it's what we do excel at as pH physiotherapists.
And I feel like it's such a powerful tool to empower the patient so that they're not going home and feeling like they have to keep Googling and keep going on those forums and, you know, driving themselves wild with like the fear. Right? I lit, I just had a message on Instagram today from somebody who was like, , you know, I'm waiting to see my OB at a, you know, at a major Toronto hospital.
Uh, I have prolapse, I have this, this, and this. Should I go on bedrest until I can get this appointment? And I'm like, you're four and a half months postpartum with, you know, potentially a child to take care of as well. Right? How could you imagine bedrest for Yeah. Prolapse, you know, or, or for leakage or heaviness and, but these are the thoughts that our clients have, and it's okay if you have these thoughts.
I had similar thoughts, maybe not about [00:34:00] bedrest, but I remember being told casually by a friend who was a pelvic health physio. When I was like five, six weeks and I was complaining about prolapse and heaviness symptoms. She's like, well, you shouldn't be lifting your baby. You know, if you're happy, those symptoms or you shouldn't be carrying her.
I'm like, are you gonna carry her for me? Right, right. What other choice do I have? But even though I knew better, I still got into my head and I was like, and then I started to resent every time my baby wanted to be held for hours because I felt like that was making it worse. Mm-hmm. . So for anyone listening, I know it's hard and I love that there are even from, like, my daughter will be five this year, so like, it hasn't been that long, but there's been so much more.
Maybe it's just because I've looked more for it, but there's been so much education and empowerment in women's health and pelvic health and even amongst p fittings and p reuse. So I'm really grateful for that. , can you talk about two things? So we, we, you had mentioned why, uh, in pregnancy it's a contraindication.
Mm-hmm. [00:35:00] Because I would love to hear that cuz I, I know some people who are, they've had their first child, they wanna have a second one. They're wondering if they should use it to prevent. And then the other piece is, is puse prevent. Preventive of worsening of prolapse.
Cara: Yeah. Okay. Two great questions. So the pregnancy one, so, , loud and clear, I will say that, , women who are currently pregnant can still use a pessary if, uh, overseen by their obgyn.
Okay. So I, as a physiotherapist, will not fit, cannot fit somebody if they know that they're pregnant. And the reason for this is they're in the literature. In some studies there has been a slight increase in risk of infection. With pessary use and we certainly don't want to, , we want to minimize that Yeah.
During pregnancy. And so, yeah. So if you do have symptoms and you are planning to be pregnant again, or you are currently, but you think you could use a [00:36:00] pessary, certainly speak to your overseeing physician, , about this. Cuz it might still be an option. We just can't see you at our clinic and a physiotherapist can't see you, but there is.
Okay. That's great to know. Good. Yeah, absolutely. , and your second prevention. Yes. Prevention. I love this question and I wish I had a straight answer for you, but we just, we have some really exciting, uh, research that I'll speak to you in just a second coming out right now. But, uh, the overarching answer here is we just don't know yet.
Hmm. This is a pretty tough, uh, research question to investigate. Yeah. Without confounding variables. Right. So, , we do, we used to think, and, and they do a great job at this, but they u we used to think that pessaries were primarily and only solely, uh, for symptom management and that's still what they really excel at.
, you're uncomfortable all day cuz you feel this bulge between your legs, put a peor in it might [00:37:00] resolve it, , greatly or even abolish that feeling. Uh, so that, that's wonderful. However, what's even more exciting, we've got a little bit of, uh, research coming out right now, , showing that with prolonged pessary use, some studies have found that there is actually a closing or shortening of some of the, , muscles and space.
So the ator hiatus, , in the pelvic cavity. The idea being with prolonged PE reuse, the idea being that if I. If any of us casted somebody in a Dorsey Fleck position their ankle and Dorsey Fleck position and left it there for a year, there would be changes. Yes. In the connective tissue, in the ligaments, in the fascia.
Right. Yeah. , so we're wondering, oh, interesting. Could something similar be happening here with prolonged support of the organs such that [00:38:00] the supe, suspensory ligaments holding the organs, they can't stretch as much. Yeah, exactly. Exactly. But we just don't know right now. , and there's inconclusive evidence because just to be fair, I also have to mention Nu another study that found that, , after putting a PEs history in and having it in there for a little while, there was actually a widening of the lader hiatus.
So first thing, You can almost find a study to, , support anything,
Surabhi: anything, literally. Well, if you've done research, which like I've, you know, when I've done research, you, you realize how easy it is to manipulate the p-values or whatever to make it work, whatever you wanna say. Mm-hmm. . And so I guess it's one of those things that needs more, you know, more research and maybe over time will know more.
Exactly. I, it makes sense theoretically anyways, why that would happen when you cast, you know, the example that you use when you cast someone, but in the example that you, when you cast someone, you, you, it also makes sense that it would weaken the [00:39:00] muscles from being casted because you are, it's disuse, right?
So perhaps there's a bit of both. And I'm curious if they've done any studies where they've used it and partake in a muscular training program right. At the same time, so that they can actually see what the, you know, overall
Cara: outcome would be. Yeah. Okay. Two things there. Absolutely. I like that train of thought.
The idea behind why they found a widening of the space mm-hmm. was actually that, and, and the researchers are hypothesizing, right? We're, we're just all doing our best guess. But the idea was that if we feel like there's something falling out of our bodies, cuz I will get clients who say, right, is my bladder gonna end up on the floor?
Is it gonna fall right outta my body? And so then there's an opportunity to do lots of anatomical education that the bulge that you're feeling is not actually your bladder and not actually your rectum. It's the vaginal walls that are pressing in and nothing is going to fall right outta your body, onto the floor.
, so yeah, what the researchers actually hypothesized is [00:40:00] that those women who felt that symptom all day, every day of something falling out were actually, basically hyper being their muscles to try and hold that organ inside their bodies and get rid of that awful sensation. And so when they put the pessary inside, they no longer had to clench every moment of every.
Right. They just let things relax a little bit. So that's important. And the other important thing is I do often have women come in, then they say, oh, but is this going to weaken my muscles? That's the opposite thing of what I want. And I do just want to say that we don't have any research to suggest that putting this brace like device inside will weaken any muscles.
Actually, I really like, this analogy that I'll quickly share. Pelvic floor muscle strengthening and pessary use simultaneously. Now depending on the grade of prolapse, sometimes the prolapse is sort of sitting right in the uh, way or the line of where [00:41:00] the pelvic floor muscles are trying to close around.
So the metaphor I like to use is elevator doors. Uh, there's a box sitting in the track of the elevator doors. Elevator doors are our pelvic floor muscles. The box is that organ that has descended a little bit. And if you're doing your pelvic floor muscles, it's training or strengthening really diligently.
If that organ is in the way, you're only going through a certain range of motion, not the full range of motion, cuz you're,
Surabhi: that's a great visual. Can just picture a boom, boom and then it starts to beep and you're like, , get that box outta the way. So that makes sense. So if you lift that pelvic back up, you can actually train the muscle and it's full range of motion.
Cara: Exactly. Exactly. And there's a little bit of proprioceptive awareness with the, the, , pessary being in there. So the. The golden pairing really is pelvic floor muscle training as best as possible. All the education regarding constipation, lifting, et cetera, and pess use, love it. In my very biased opinion,
Surabhi: and you know, and I think it's an important thing to consider because a lot of [00:42:00] people con i I that I hear from anyways.
PE Pere are often a last resort thing. Mm-hmm. , and that's what you just said is like, well, you may be doing all the right exercises and the right things, but if you're not able to train in the full range of motion and, or it's limiting you and you're actually like gripping heavily all day, you know, that often worsens, incontinence, , right?
It's, yes. You're con you're constantly gripping and then you can't even, you know, when Yeah. You experience more leaks. So it all kind of ties together. , how much does a pessary cost or what are the, what's the range? Is it covered by OHIP In Ontario we have public, you know, healthcare. Is it covered by that?
Cara: Mm-hmm. . Right. So whether an individual goes to see a urogynecologist or a gynecologist or myself, the pessary is not covered by oip. Okay. Okay. So that is out of pocket. And in Ontario, typically the cost of them will range anywhere from about one 10 to one 40. I've heard. , now the good thing is that PE [00:43:00] typically last for minimum of one year, sometimes more.
Uh, yep. So the, some manufacturers do recommend that the pesi be replaced once annually. Uh, so something good to just check with your provider or your fitter, , but they aren't something that have to be, has to be changed once a month, let's say. So. Mm-hmm. , , yeah. And
Surabhi: then when you, when you're a year older, let's say, do you have to be refitted, right?
Or is there change with Yeah.
Cara: Right. If the pessary is still fitting, uh, retaining the prolapse, uh, still comfortable then nope. Uh, it can be, sometimes people will use the same shape and size for five, 10 years. Wow. Nice. , and sometimes our bodies do change, whether that means we have to go to a little bit larger pey, but also sometimes we have to go to a smaller pessary.
Maybe as we age in those decreased estrogen or, , different things like that. Maybe there's some atrophy in the tissues and we have to go to a smaller size. So it can, can vary, uh, throughout the [00:44:00] lifespan. , but on that note, I often get women who ask, is this just a temporary fix or could I, how long can I use this a pessary?
, and you could use a pessary if it serves you well and you don't have any, uh, risks that sort of pop up. for the rest of your days on Earth. Mm-hmm. . So there is no sort of an expiry, oh, you can only use this for a year, and then you have to look at something else. I have women who have been using pessaries for decades successfully.
, and so that's really encouraging to hear for women. Cannot. That's really great. Does not want surgery. Mm-hmm. and
Surabhi: for people. And that's, that's really positive to hear because their surgery has its own risks, you know? Right. And what are the risks of using a pry? Are there any risks? Yeah.
Cara: Yeah. So yes, there are a few.
, and so adhering to your fitting, uh, practitioners guidelines is very important. Uh, the most common risks are, , I, I even hate saying this is a risk, but one of the symptoms is there can be a production [00:45:00] of a little bit more vaginal discharge. Now, there is nothing dangerous about this. This is why I don't like categorizing it as a risk.
But, uh, I do educate my women because they could, they, they will wonder, oh, this is a change since I've been using the pessary. Is this okay? Is this indicative of infection? , so I liken it too. If I put a throat loing in my mouth, my mouth starts to salivate a little bit more. It's your body's response to there being something in there.
And of course, discharge is the way our vaginal canals clean
Surabhi: themselves, right? Clean. Yeah. So it's like trying to flush this thing out. And then they're. Because, yeah, it still perceives it as a porn object, so that's good to know. Yeah, yeah.
Cara: So discharge, but in the absence of it being green or smelly or itchy or anything like that, that's totally normal.
So that is one, but that is one of the most common things that women will report with pess reuse. , another potential risk is it falling out. , now this should not happen, happen just during your ADLs, but if a woman is straining, whether that's on a toilet, whether that's lifting heavy, whatever it might be, I mean, [00:46:00] we expel humans, babies out of that of our bodies, if any of us push hard enough, we can expel a PE three.
So I also like to let my note, my women or my individuals know that that could happen, , and do X, Y, Z, and it's, , it might not mean that it's. An ill-fitting pessary if you are straining, but if you're just walking down the street, then it's, and it's Oh, out then. Yeah. Yeah. Then, then we gotta refit you.
, now one of the most common things that I will see that we need to deal with is some bleeding. Mm-hmm. So there can be some wear and tear on the vaginal mucosa, uh, with the pessary inside. If you have anything on any part of your body that's rubbing, there's the potential for irritation breakdown. Right.
Yeah. Friction. Absolutely.
Surabhi: I'm assuming the walls of the pessary are smooth, they're not mm-hmm. like sharp or irritating.
Cara: Yeah. Right, right. Absolutely. Yes. , And [00:47:00] so if this happens, this is another piece that I'm always educating my women on. This could or, or may not happen, but if it does happen, these are the steps that we take.
And sometimes that means we just need to take a little bit of a pessary vacation. , we keep that thing out for two to four weeks. Women really do not like to do that. But, , sometimes, yeah, that's what
Surabhi: everybody needs because they're used to feeling good and then they're like, this is not happening anymore.
Yes. Are there people who, how would you know, for example, if you're using a pessary and you don't need to use it anymore? , yeah. A trial or, or do people do, do a trial without it and see, oh, maybe my symptoms have improved. Yeah. My strengthening has, you know, worked or,
Cara: or whatever. Yeah, absolutely. , so yes, particularly let's say in the postpartum period.
Mm-hmm. , uh, for, let's just take a look at like the 12 months post giving birth. , put a pessary in, do lots of pelvic floor muscle strengthening, whole body strengthening, lots of lots of education. Uh, our bowel movements are [00:48:00] easy and consistent, et cetera. Uh, yeah, uh, that's exactly what a woman would do.
Okay. Take it out for half a day and see how you do. Are the symptoms, do they come back within that timeframe? , and then just slowly progress that, uh, that timeframe of not using the PS three and see how you. Nice. So that's exactly it. Yes. And in that, particularly in that stage of life, the postpartum stage, that's where we would see, uh, the most likelihood of using the pessary for a finite time and yes.
Not needing to use it
Surabhi: again. Yeah. Because there is a lot of change, right? Mm-hmm. , especially as the person starts sleeping better and eating more. And I always say it takes time. Everyone's like six weeks. I'm like, it can take two years to get into a routine of some kind. Yes. And, and then you're still adjusting, so.
Exactly. You know, sleep is so important for healing and I feel like that is one of those factors postpartum that you're not getting. Yes. So if you're not sleeping, your seven to nine hours a night, then your body's healing is, slowed down. Exactly. Exactly. And so pessary use [00:49:00] might be really, really beneficial either short or long-term.
Cara: Yes, absolutely.
Surabhi: And let's switch gears to talk about stress urinary incontinence because mm-hmm. , there's probably a lot of similarities in terms of its use mm-hmm. , but what is it and who would be an ideal candidate for pessary use? Yeah.
Cara: Okay. So stress urinary incontinence is the involuntary loss of urine, , with anything that puts pressure, intra abdominally, which then puts pressure on our bladder.
So those things could include coughing, sneezing, running, jumping, turning over in bed, going from a sitting position to a standing position. Any of those things. I have just had a few clients come in who say, but I'm not stressed. That's not the stress we're talking about. , it's physical pressure on our bodies, and then on the bladder , but
Surabhi: I'm not stressed. That's funny.
Cara: dear. , so in that instance, how a pessary can help. And we get stress urinary leakage for a couple of different reasons. Sometimes [00:50:00] the bladder neck, so that's where the urethra, the tube where we pee out of, and the bladder meet. So sometimes the bladder neck doesn't, isn't really supported with our fascia and our soft tissue.
And so it moves a lot. And so that allows learn urine to sort of squeak through the urethra. , sometimes it's due to deficiencies of the urethra itself. So many different reasons for stress urinary contents. However, the way the pessary can help is that it puts a little bit of extra pressure right on the bladder neck or the urethra so that we can still, not so much that we can't.
Uh, when we want to, but a little bit of extra pressure. So it decreases the likelihood or severity or frequency, uh, with which we might be accidentally leaking urine. Uh, so that's how it, uh, how it works. So it's, it goes inside the vagina, puts pressure on the urethra, the front wall of the vagina and the urethra or bladder neck.
, so that it decreases the chance of loss of urine. Uh, [00:51:00] sometimes people will say, but can I still pee with a pessary? Yes, you should still be able to pee. It's very, it would be a very ill-fitting pessary, uh, if you could not pee. And that's why I always have my women try to pee before they go. Yeah. , from that initial appointments.
That's important. So it's
Surabhi: just offering a bit of support essentially without it being like a total restriction. Yes. Nice. And cuz I know prolapse and stress incontinence can often also, you know, come together. Yes. So that sounds like, you know, it's a double win for people who have both, where it would offer that support for both.
. . And what is, I guess, a success rate or how successful is it for stress urinary urinary continents?
Cara: Yeah, so in the literature it's about the same as for pelvic organ prolapse. , yeah, so, so that's what the literature says. I personally find it can be a little bit trickier, uh, to. As successful results for stress urinary [00:52:00] incontinent, uh, versus pelvic organ prolapse.
The reason typically being is there are fewer pessaries on the market for stress urinary continents. And the ones that we do have don't always stay in the most ideal spot. Right. For them to work the way that I just
Surabhi: explained. Yeah. Cuz if it's sitting up near the cervix, it's not necessarily gonna provide that pressure that you need Right.
In the right spot. Right.
Cara: Yeah. And maybe it's sits beautifully when the, uh, individual is laying down on the treatment table and then they get up and they do those 15, uh, squats or jumping jacks or whatever it might be. And sometimes it shifts, right? And then we're no longer getting the benefit. So still absolutely worth a try.
, and like I said, the literature is about the same. So, so yeah, that's, it can be helpful for, for some women. Absolut. and
Surabhi: people have stress urinary incontinence, whether they've been pregnant postpartum mm-hmm. , no matter the age. So I feel like yes, that's something that if you're dealing with repetitively with no, you know, because there's so many strategies that we can use for [00:53:00] stress urinary incontinence, but if those aren't working, then why not try , something like a pessary?
Yeah,
Cara: absolutely. And do you see, yeah, I was just gonna say before we move on from stress urinary incontinence and pelvic organ prolapse, there is just one other piece of education that I would love our listeners to know just in case they do experience this themselves. And that is actually, , the reverse of what we're talking about here, where sort of two birds with one stone can be taken care of with a pessary cause that absolutely can happen.
For sure. There are pessaries that, , are designed specifically for pelvic room prolapse and stress urinary incontinence. So, bingo, wonderful. However, Due to anatomy. Sometimes we, let's say a woman comes in and says, uh, she has pelvic organ prolapse, but no leakage. Wonderful. We put a pessary inside and it actually corrects the anatomy so well.
So, uh, the urethra. Uh, let me just back up for a moment. Sometimes when we have pelvic organ prolapse, uh, all of the tissue [00:54:00] is sort of dragged down towards the vaginal opening. , and that actually puts a kink in the urethra, the tube where we pee out of. And so that actually, uh, can mask urinary incontinence.
So we call it ma masked incontinence. And then when we correct that anatomy, uh, then we straighten out that tube, and now it's like this big waterfall, or sorry, a water slide for, , the urine to sort of slip right down. So that is another potential risk of pessary use, is that we can unmask that incontinence and that, uh, is not what anybody wants to hear , but that can happen.
So I do like my women to know that, that that's, that could happen. , , sometimes people think, oh, if I have one, I have to have the other. For PE burning prolapse and stress urinary incontinence. No, they are two different mechanisms. Yeah. , underlying causes, et cetera. , so yeah, just to be aware of that.
And sometimes we can just switch out the pastory for a different kind. And sometimes unfortunately, we have to [00:55:00] choose the lesser evil, whether that is some incontinence or the symptoms of the pelvic organ prolapse. Hmm. And that's sometimes the reality. I try to, not sugarcoat, but give a very realistic expectation and snapshot of what life could be, the pros and the cons with pessary use.
Uh, whether it's for stress urinary conscience or pelvic organ prolapse. So
Surabhi: that's a really important point because I have, , it's, I, I'm sure that's not uncommon for it to happen where you're like, I corrected one thing and then I feel something else. And sometimes you're like, oh, did the pessary cause this?
But it can just be the unmasking of preexisting issues. Right. And it's exactly, , You know, we are all human beings. We're not invincible. So there's not always a perfect solution. It's the best option. You know, sometimes you're looking for rather than magic cure for every single thing that's potentially, you know, wrong with me.
Right. , and I think that's important and I'm glad that, you know, you're honest with your, your patients right off the bat because I think they prob probably anyways, they respect that rather than [00:56:00] being given this false promise of, Hey, it'll fix everything. And then when it doesn't, you're like, you know, it reminds me of orthotics how oftentimes people will just get their ortho orthotics made here and there and they're like, the doctor or the O chiro or whoever said it would fix my back pain.
And I'm
Cara: like, Why. Right.
Surabhi: But it's, they're being sold this message and then when it doesn't work, they're really disappointed that they spend $500 on, you know, orthotics. And also insurance companies cover orthotics. Do they cover, pessary as an orthotic, like a aid or,
Cara: so some insurance companies do as Yes, exactly.
Like an orthotic or a medical device or a brace. Hmm. Not all insurance companies do. So it's my, one of my personal missions here to educate every insurance rep that I can. can,
Surabhi: it's wild that this is such an important issue and it's not covered like, right.
Cara: Like
Surabhi: orthotics are, yes, it can be very helpful for some people, but it's not medically [00:57:00] necessary for most people who are using it. Whereas a pessary like it can change someone's life.
Cara: Absolutely. And insurance companies, lots of them will cover incontinence product. So the diapers on the wow, shelves, and then some will refuse to, to cover a pessary. So we, as healthcare practitioners need to get our voices out there and be advocates because it is wild that these aren't covered.
They, it's nobody comes into my office wanting one of these. No. They're, you
Surabhi: know, they need it.
Cara: Yeah. Yeah. . Absolutely.
Surabhi: Awesome. Well, we have a few more minutes and I have some final thoughts and questions for you, and I would love to find out what you are reading these days. What's your favorite podcast or book?
Cara: Yeah, absolutely. Well, thank you for those questions. Actually, it was one of my goals during the holiday season to read a fiction book because I have been inundated with research articles for the past number of months. We were just just [00:58:00] revamping, totally revamping a pessary course actually.
Surabhi: Amazing.
Cara: And so we, yeah. Yeah. And so our first, course that was totally revamped was in December. So I am done with everything that is nonfiction and research related for a little while. And so I just read this fluffy mystery and during, over the holidays, and that was wonderful, but most of the time it looks like personal growth or research articles about Pelvic Health.
Surabhi: I get it. I'm like, my bookshelf is all personal growth, life, mental health, all the, Non-fiction, and I can't remember the last time I've read fiction. So yes, that's a good reminder to myself to just take a break and do something that's just Yes, creative. Exactly. Tell me, what are three things you do for yourself every day?
Like rituals or self-care things make you yourself feel better?
Cara: Okay. One great. A recent practice of ten second gratitude practice. I, that I just love, [00:59:00] love, love. I'm standing in the shower and uh, and just filled with gratitude of the abundance and accessibility of, or accessory of hot, fresh water that most of us.
That I don't even, you know, that I take for granted every day. I just turn on the tap whenever I want. Yes. And I never have to worry about it running cold or not being there or being dirty or, you know, whatever it might be. So that is one, little ounce of gratitude practice that I can put in every day and feel so good to start the day off like that.
Love it. The other thing is I try my best, most days of the week to get some exercise. Exercise for me. Looks like maybe running at the gym, maybe hot yoga. But my greatest love is Latin dancing, so,
Ooh. Ooh. I didn't know you dance. Love it. .
Yes. So a couple times a week at least. Gotta hit the dance floor.
So good for the body, for the soul, for the mind, for social connection. Yes. Oh my goodness.
Surabhi: I recently [01:00:00] restarted dance in the fall and I'm doing Bollywood dance, I'm Indian and Bollywood dance is like full of energy and yes vibes and like it has brought back life into my body. And like just after, you know, covid and parenting and transitions and starting my own business, there's so much work and tasks to do and it's just such a way to, like you said, just come alive.
And that social connection piece is huge too. I love that. So gratitude. Yes. Dance. And what was the third thing you mentioned? Exercise.
Cara: Yeah, exercise. Yes. Yeah. So yeah.
Surabhi: Love it.
Cara: Those are some of the things that keep me sane.
Surabhi: tell me what is something that you're really passionate about these days?
Cara: Yeah. Oh, good question. Really passionate about these days. One of my friends, okay, I'm gonna say transparency. One of my friends and colleagues has a sweater that says, and it's from one of her friend's brands, how are you? And then in smaller font, right [01:01:00] under, it says, really? So that like we, how many times a day do we say, oh, how are you?
How's it going? And we give this, , yeah, right? Yeah.
Surabhi: We're like, we're good. And you're like, actually I'm not good. Right.
Cara: Yeah, absolutely. So, , providing a space and being really attentive to those in my life whom I come in contact with, of creating space of I don't need that, or I welcome you if you so choose to not give me that sort of blanket statement or off the cuff answer.
And be transparent and, let me know how are you really, really, , yeah. Yeah. So, yeah, I think, I mean, we've had really tough couple of years. Yes. So, being transparent with how we're doing, and what we need and how I can be of service to others and at the same time being transparent myself.
Like, I can't expect somebody else to be, if yes, if I'm not willing to dive to,
Surabhi: like, you have to almost lead, lead that way. Right? Yeah. Yeah. I agree. Yeah. And you know, that ties into the next question. If there's something you could change [01:02:00] about the world, what would it be?
Cara: Mm .Ooh. I think, oh yeah, good question.
This is gonna sound so cliche and I'm wearing the a shirt that says Born to Love. But if we all, I love it. Just loved a little bit more. I read this beautiful poem the other day that love is smiling at the cashier. Love is putting the earth worm on sidewalk back in the soil. Love is just all of these things, all of these, like, there are probably a million moments in each of our daily lives where we could express a little bit.
Love. Yes. , and I think this world would be much more beautiful with, with that.
Surabhi: And often when you are in a dark place, giving love helps you also receive love. Yes. It kind of is, it's, it's a two-way street, right. Because sometimes it's like, oh, but I'm having worse say than so-and-so I don't have any love to give or energy to give.
And it, it might just be that smile at someone or love the earth worm thing. I see a lot of kids being really aggressive with insects and animals and like, not aggressive on purpose, but like, they just think it's [01:03:00] theirs to own. And I'm like, right, these are still creatures who have their own lives.
And yes, we were going for, uh, bike ride home with a kid at her daycare and the kid was like laughing as she was squishing the worms with her bike on a rainy day. And my daughter's like avoiding going around and like taking her own time. And I was like, just let's, I love that.
I love the, that, that whole message. And where can people connect with you? Yeah, so emailed Instagram, what's what, where are you at?
Cara: Yeah, so best way actually is old school and coming to my website and sending me an email. love it. But I do have a few other options as well. You can find me on Facebook, just Toronto Pessary Clinic, clinic.
Also we have a branch in Saskatoon, Saskatchewan, so Saskatoon Pessary Clinic. Amazing. You can find me on Instagram, but I'm not super active. I really am an old soul here. So shoot me a message on Facebook or on Instagram [01:04:00] or send me an email or give me a call, numbers on the website as well.
Surabhi: You have a real phone number, I don't, but you do. So, give her a call and find her i'll. I'll also include links, you know, toronto pessary clinic.com. Saskatoon pessary clinic.com. and your website, and your email and your Instagram, , I'll include that link with the podcast when it comes out.
My last question, what would you say is your biggest strength?
Cara: Oh, biggest strength. I have been told creating a space for people to feel safe to share things that maybe they don't have a platform or not feel comfortable sharing elsewhere. And this is probably why I, and most of us are in pelvic health. Pelvic health is very, can be very private. Lots of emotion, like you said, attached to it.
Lots of social and societal and religious and cultural narratives Yes. Attached to it. Yeah. And to just create that space to try my best [01:05:00] to have my patients be seen and feel heard and feel validated. I think I am told that that is one of my strengths and that is something that I think lends itself well to pelvic health.
And I think a lot of us in this profession really excel at that. I agree.
Surabhi: And having met you only once, but still, I would say that I agree. You give off a very welcoming and safe vibe. And I definitely felt like, okay, you know, you see me and I felt validated just even in conversation with you. So, I'm sure your clients are just so lucky to have you.
I'm so grateful for this conversation and your education on pessary fittings. What, who it's meant for, how it helps. And I'm can't wait to get this episode out there. If you're listening to this, whether you are a practitioner yourself, a person who found this helpful, please share this with your own community, whether it's on social media, your friends and family.
Anyone with a vulva really would benefit from listening to this because, [01:06:00] anyone could maybe benefit from this at some point in their lives. So thank you so much.
Thank you so much for having me. That was wonderful.
