Q&A with Dr. Betsy Greenleaf, the first female board certified urogynecologist in the United States
Dr. Greenleaf: You know, this is very interesting and is becoming a very big topic of discussion, not just the vaginal microbiome but microbiomes in general. So the terminology “microbiome”: a biome is basically a little environment. So it’s all the organisms that live in and around an area. So we think of the Amazon rainforest; that’s its own biome. But on a microscopic level, we have the microbiome.
Ironside: What is an example of a microbiome in humans?
Dr. Greenleaf: So there’s different areas of our body such as our mouth, our intestines, the vagina; each one of those areas has its own bacteria, yeasts, and organisms that live in balance. The vaginal microbiome is so important for women and it can get out of whack. The first thing you may notice is that you may develop an itch or a burn or an odor. And for people who study and treat the microbiome we know that’s a sign the microbiome is out of balance. And so there are healthy bacteria that live in the vagina that basically, they’re called lactobacillus, and the lactobacillus is what keeps our vagina in balance. And so things like stress or diets high in sugars or being on antibiotics or changes in hormones from pregnancy or menopause, these things can affect the healthy lactobacillus’ ability to fight off “the bad guys”.
Ironside: What can a person do when the “bad guys" get the best of the healthy lactobacillus?
Dr. Greenleaf: when the lactobacillus is no longer there because it’s been affected that’s when we’re at much higher risk for vaginal itching, burning, odor, which may be termed a “vaginitis,” an inflammation of the vagina, and that can happen from an overgrowth of bacteria or an overgrowth of yeast. So it’s really that we want our biomes to be in balance. So it’s really this whole fascinating area of study now and even with some of the laboratory tests that are coming out we’re discovering more and more about what is a healthy microbiome. They’re discovering bacteria that lives in the vagina that nobody knew existed because of some of these advances in the testing that is out there.
Ironside: That’s awesome. Can you explain how you test this vaginal microbiome?
Dr. Greenleaf: Sure! So it’s still interesting because the standard of care for testing for vaginitis is really still stuck in the 1950s. Unfortunately the standard of care for when you go to the doctor for itching and burning is they will test your vaginal pH. That’s actually a nice, easy way for people to know and can actually do it yourself at home. There’s a lot of different type of pH paper that you can find on Amazon. So the normal range of pH for the vagina should be between 3.5 and 4.5, which is very acidic.
Ironside: Is it enough to have a vagina that is acidic to maintain good vaginal health?
Dr. Greenleaf: The pH level alone is not all that you need to know. Like I said, this was considered standardized testing and what we’re taught in medical school, and a lot of doctors are still doing as a standard of care. It’s still kind of antiquated and other than pH, there’s ways for us to look under the microscope and see inflammatory cells or there’s something called a “whiff test” where we apply a bit of a base to a slide. If there’s an odor associated with this base with the vaginal secretions, then we know there’s bacterial vaginosis. So really that’s what’s considered standard of care and doesn’t actually test the microbiome. It wasn’t until about 15 years ago that laboratories started developing more advanced testing that looks at the DNA presence of what’s in the vagina looking at the vaginal secretions. A lot of time this can be done with just a simple Q-tip like swab that’s sent off to a specialty lab to look at exactly what type of bacteria is there. There’s two (2) kinds of tests.
Ironside: Can you describe these tests?
Dr. Greenleaf: The first one came out initially called a “PCR” test. The PCR test looks at the DNA presence of bacteria and yeast and tests to see if there’s any kind of healthy bacteria. That can be done in a doctor’s office. Now, I have to say, there’s still not a lot of doctors that are doing that because it’s still not considered 100% standard of care. So unfortunately, I hope we’re moving in that direction because I find that in general when it comes to advances in medicine that insurance or the general medical population lags about 10-15 years behind the technology. Nowadays, they’ve gone on to not only look at the DNA presence of the bacteria but there’s another type of test called “Next Generation Testing.” The Next Generation test actually is able to test and identify even more types of bacteria and microbiome that’s there. There are some commercial companies that are developing tests where patients can go directly to their websites and actually order these microbiome tests. The only thing I caution you with some of the Next Generation Testing is it’s really for information purposes only and not used to diagnose or treat because we’re finding out so much more bacteria that exists that we never knew was there so clinically they’re not 100% sure what to do with this knowledge. There are some laboratories out there that are doing major research on discovering what is “normal,” what is “not normal” when it comes to vaginal health, so I think in the next 5-10 years we’ll see a big shift in the ability to test for this and also to help women balance out their microbiome so they don’t ever have to deal with itching, burning and odor ever again.
Ironside: It’s so wonderful, this kind of pioneering work that you’re doing and we just love hearing about this. So the next question that I wanted to ask you is about the use of lasers for vaginal health. Can you delve into that for us please?
Dr. Greenleaf: Sure! And this is also connected with the vaginal microbiome, so we’re gonna take a step back and people might say, “Why do I need to care about my microbiome?” and you know, “why does it really matter?” If you’re treating itching, burning, odor that’s one thing; but there’s actually some bigger problems that can happen when the microbiome is thrown off. Number one, like we were talking about, you’re at much higher risk for recurrent vaginitis but you can actually have recurrent issues with urinary tract infections, and it can actually cause infertility if the microbiome is not off. So this is something where if a patient is struggling with infertility, maybe balancing out the microbiome will help. And now they’re even doing research into sex drive and microbiome. I’ll connect this with lasers in just a minute but – the thought is that there may be this vagina-brain connection. Once you explain it, it kind of makes sense, but scientists are now currently trying to prove this: if the microbiome is off in the vagina, that might not ideally be the best time to reproduce and this feedback signaling to the brain to shut down sex drive; so that’s something that we’re looking at.
Ironside: Interesting. How does this connect with the use of lasers for better vaginal balance?
Dr. Greenleaf: So how to connect it to vaginal lasers, this is where it gets really interesting: when a woman is menstruating and the vaginal tissue is being exposed to hormones like estrogen, the tissue is going to be nice and thick and healthy, that’s gonna help with moisture in the vagina and help with comfort. The other thing is with that healthy tissue, the tissue is going to constantly be growing and the old cells are going to be sloughed off. Those sloughed off cells make up a chemical called glycogen; that’s the food source of the lactobacillus. As long as there's a food source for the lactobacillus, the lactobacillus will be there and will fight off all these other bad guys and keep the microbiome in balance. There are a number of conditions where that tissue in the vagina starts to really thin down, and when it thins, it stops sloughing off, and the food source of the lactobacillus disappears and the lactobacillus starves and dies and now you have all these other conditions. The biggest time that this happens in a woman’s life tends to be in menopause when the estrogen levels get low and the ovaries are stopping to produce as much estrogen and women are complaining of vaginal dryness or pain with intercourse. Especially during this time period we see increased risks of vaginitis and recurrent urinary tract infections. This can also happen in times after childbirth or breastfeeding those hormones are low, or even in women who are on birth control. So even though taking birth control, the body perceives the estrogen levels as being much lower and the vaginal tissue can be affected.
Ironside:What about the use of estrogen creams to address these concerns?
Dr. Greenleaf: Traditionally, the way we were able to treat this in women was using estrogen cream in the vagina. But, not that it’s a bad option – for some women it’s wonderful option and are very happy with it, the downside of using estrogen creams in the vagina is from a comfort level it may be slimy, some people don’t like that slimy sensation or don’t like having to put in creams every night or a couple of times a week. Some people are just nervous using hormones or exposing their bodies to hormones, such as women who have had breast cancer. So there’s a number of reasons – some people just can’t tolerate it. A lot of the prescription options contain something called propylene glycol as a filler that can be very irritating to the vaginal mucosa. So there’s a number of reasons why women would choose not to use estrogen vaginally. So if you’re reading or listening to this and you are choosing it it’s not a bad option, it’s just for a long time it was the only option. So what I think is really fascinating in the world of vaginas is that since about 2016 here in the United States, there’s been more focus on how we can help women with dryness, with pain with intercourse due to dryness, or microbiome problems without using hormones.
Ironside: When did lasers start to come into focus for vaginal health?
Dr. Greenleaf: In Europe prior to 2016 they really started looking at lasers for tissue regeneration. The funny thing about lasers is lasers have been used since probably the 1980’s for tissue regeneration when it comes to cosmetics. They use it for facial rejuvenation, for skin anti-aging, for skin tightening, and then all of a sudden somebody – and I wish it was me, but it wasn’t – somebody decided “if this works so well on the face and other areas cosmetically, why don’t we use it for the vagina?” And starting in Europe and prior to 2016 is being used for vaginal rejuvenation. And lasers are just light energy, and they used the light energy applied to the vaginal tissue and it actually will trigger the body to produce it’s own growth factors and can actually cause the vaginal tissue to re-grow without being exposed to hormones. So, we’ve been able to use that technology in the United States since 2016. It started out with a product called the “Mona Lisa Touch,” which is a laser that I’ve loved to use, but there are a number of different companies that are now employing their own use of lasers so there’s a lot of different laser products that being used for the vagina. I think what happened with laser vaginal rejuvenation it really kicked off this industry of “wait a minute, there’s a lot of things that we use for regenerative purposes cosmetically, let’s now apply this to the vagina.” So lasers were the first option and now we’re starting to see things like red light therapy, which they know is great for the skin, being applied to the vagina; and something called “Carboxytherapy'' where you use a gelled carbon dioxide that they use – once again it was taken from the cosmetic world and they do still put it on people’s face to rejuvenate the skin – but there are now options out there to be applied to the vagina. So I think we’re see in the next couple of years more and more of these products coming out to help women, and more options without having to use hormone creams.
Ironside: That is fantastic, and what I really admire about your practice is how you continue to experiment with these lasers on your own and also with fellow professionals. You spend your weekends, I know this, doing all manner of experimentation with lasers and I’m a huge fan of what you’re doing. So finally I’d like to ask you about something called a “pessary.” I think the average person does not know what this is, and if they do know, they might be a little hesitant to try it. My hope is that you can dispel this anxiety surrounding the use of pessaries.
Dr. Greenleaf: So the unfortunate thing is that 50% of women will experience or develop a prolapse, and then we have to take a step back and go, “what is a prolapse?” So prolapse is when things are drooping and dropping. So you may have heard about people talking about their bladder drop or their uterus drop, rectum drop. Unfortunately not enough people are talking about it because it’s happening in 50% of women. So it happens often because the ligaments in the pelvis have been damaged either childbirth is the most common reason, but heavy lifting or some sort of trauma to the pelvis, or severe constipation, sometimes people with really hard coughing or vomiting can put a lot of pressure on the pelvis and damage the ligaments.
Ironside: What is a person's response when this happens, what reactions have you seen??
Dr. Greenleaf: So what happens especially when the bladder drops, a woman may not know that is happening right away but they may all the sudden have problems emptying their bladder all the way, urinary tract infections, some women will actually feel something bulging out of the vagina. A lot of women's first reaction to it is, “Oh goodness I have a tumor!” and so they come into the office and we can say, “no, it’s not a tumor, it’s just that you’ve lost some of the support.” There’s a whole range of things that can be done for this. I think in general we sometimes overlook the simplest and easiest thing that can be done, which is a pessary. A pessary is a support device that is fitted for your vagina and basically is worn inside the vagina and just wedges in there and can hold up the bladder, the uterus, the rectum.
Ironside: When did pessaries come into fashion?
Dr. Greenleaf: The interesting history about pessaries is that they’ve been in use since ancient Egypt. Women used to use pomegranates, which I don’t advise, but women used to use pomegranates or rocks and place them in the vagina – something to wedge in there to prevent things from falling out. In Rome they used to do the same thing – rocks or potatoes have been reported in literature, which I don’t advise. But the simple idea of a pessary is something that has been in existence for hundreds and hundreds of years. What’s nice about it is that you can be fitted for them. They can be easily taken care of by yourself or a doctor. They should be comfortable when they’re in place, they should never cause pain. Some people think it’s something they can do temporarily and that it’s not something that can be left or something they can use long-term. But I have many patients that are very happy with their pessaries and it helps their quality of life, and you can basically have a pessary for the rest of your life. It doesn’t necessarily mean that you have to have surgery.
Ironside: What do pessaries look like?
Dr. Greenleaf: They do come in all sorts of shapes and sizes, just like the vagina comes in all sorts of shapes and sizes. The shape is determined by how well it wedges in the vagina. Some of them look just like a little Frisbee, some look like doughnuts, the more extreme ones look a little bit like a cube. So there’s different shapes and your healthcare practitioner can help determine which shape and size is the best for you. Some people feel comfortable and can be easily taught to take them in and out themselves and we may have people take them out every day and wash them; they can come out once a week. Interestingly enough, there’s no standard of care for how long they can be left in. Usually the recommendation is not to have them in place for longer than 6 months at a time. The longer they’re left in, the body will produce a heavy discharge in response to the foreign body. But a lot of times patients will ask, “will this cause an infection? Can I get injured from these things?” Very, very rare that that happens. This is a simple, easy, non-surgical way to manage a prolapse. So some people surgery is just not the answer if they have health conditions and not wanting to undergo surgery, or some people are just not mentally ready to undergo surgery. So this is something great that can kind of bridge that gap so you can decide if you eventually want to have a surgery.
Ironside: As a surgeon who has performed many surgeries to correct prolapse, what have you seen regarding long term results?
Dr. Greenleaf: The unfortunate thing about pelvic surgeries for a dropped bladder, or uterus, or rectum was that we used to believe that you got surgery and that was great, and you’d be good for the rest of your life. Unfortunately none of those surgeries are considered permanent and a certain portion of patients once they have surgery are at higher risk for things drooping and dropping again. It would be nice to be like your appendix, if your appendix is out it’s out it’s not like prolapse surgery and never going to happen again. Pessaries just may be a great option for somebody who’s a little nervous about the idea of surgery or just not ready for it yet. Sometimes we even use it to try out how a patient is going to feel once the bladder and uterus is put back where it’s supposed to be. It can be used as a diagnostic way to evaluate a patient’s condition. But once again, they’re really easy to manage. Depending on the shape and size you can still engage in sexual activity with them. Some people think you can’t have sex with them in place, certain shapes and sizes you can. They don’t necessarily need to be taken out. Just when it comes to care for them, they can easily be taken out and cleaned with soap and water and then put back. Some people can take them out themselves, others will go to their health practitioner to be cleaned. But sometimes, we’re talking about bladder and uterus, but if the rectum is falling these pessaries can also hold up the rectal side of the pelvis and they may help people who are getting constipation from the rectum drooping and dropping. That’s another advantage of the pessary. It’s fun when you use something that really hasn’t changed in technology in hundreds of years and I think that we as healthcare practitioners forget to go back to the basics, so this is a great option for people.
Ironside: I love how when you treat you’re able to cover this gamut of treating the person with these very modern approaches such as lasers, looking into the vaginal microbiome, but as you said that sometimes going back to the basics of the most simple things can prevent people from undergoing surgeries that may or may not help them and also offer a comfort level about something a pessary. You’re giving them this option of something very, very basic that they can manage themselves and they’re not going to be afraid that it’s unsexy or unappealing; they’re just going to feel more like themselves without any surgical intervention. I want to thank you so very much for joining us today Dr. Greenleaf. It has been outstanding talking to you.
Dr. Greenleaf: Thank you so much. I am very passionate about these things and have such a great time talking about this stuff, so if you guys are on social media follow me. If you look for Dr. Betsy Greenleaf you can find me pretty much anywhere; I’m all over social media. I have a podcast called “Some of Your Parts” and we have another podcast called “Body Mind Spirit.” Last but not least, I have a website called “The Pelvic Floor Store” that we’re constantly trying to put out new and improved information. Thank you once again for having me.
Ironside: Thanks so much.
Dr. Betsy A.B. Greenleaf DO, FACOOG (Distinguished), FACOG, FAAOPM, FPMRS, MBA
America's "Down There" DoctorTM,
First Board Certified Female Urogynecologist in the United States
Board Certified in Obstetrics/Gynecology
Board Certified in Female Pelvic Medicine and Reconstructive Surgery
Board Certified in Procedural Medicine and Aesthetics
Masters of Business in Strategic Management and Innovation
Follow her at:
I have an obturator internus?
The obturator internus sits inside the pelvis and travels around out the back of the pelvis to the femur (thigh bone). This muscle rotates the hip out, moves the leg wide when it’s forward, and stabilizes the hip.
The obturator internus can become tensioned or spasmed from overworking, muscle imbalances, injuries, and postural changes.
Some symptoms of obturator internus muscle tension include:
The obturator internus has many pain referral sites. So symptoms can vary from one day to the next.
Other symptoms that would indicate that you should be checked for tension in the pelvic muscles include:
I commonly see high-level athletes hold tension in the obturator internus muscle. Gymnasts, horseback riders, spin class cyclers, runners, and dancers tend to have spasms here. In any post-operative hip surgery in which rotation is limited, as with a hip replacement, this muscle can be a source of pain or contribute to the onset of urinary incontinence.
I find that many patients have gone to traditional PT and had no relief. Some have had X-rays, MRI, and injections.
During an internal pelvic floor evaluation, when the muscle is pressed on by the therapist, it often reproduces the pain the patient has been experiencing. Many patients are relieved to find out where the pain is coming from and that it is easily treated.
I think back to my orthopedic treating days and wish I could have sent all of my patients with hip pain not finding relief with traditional methods, and referred them to a pelvic PT. Besides a Gynecologist or Urogynecologist, a pelvic PT is the only person checking manually to see if the obturator internus is a source of pain.
I have a special interest in the obturator internus because of personal experience with symptoms. Always having a tendency towards muscle tension, after pregnancy and abdominal diastasis weakness, my usual exercises resulted in pain. Pain in the hip, painful sitting, and when enough tension builds I am scared to sneeze! But these muscles can be stretched and released, and the muscle imbalances restored.
If you have any of these symptoms, seek a pelvic physical therapist. A quick evaluation of the pelvic muscles can rule in or out the obturator internus and a treatment plan can be made for you.
vincent's story: pain with sitting
Written by Becca Ironside, PT
Vincent found our clinic by chance. He scoured the Internet, looking for a reason to explain the confounding pain in his pelvis. Vincent had a high-stress, corporate job wherein he sat all day long. He began to notice pain in his perineum while sitting. The longer he sat, the worse the pain became.
The final symptom which prompted Vincent to become desperate for help was testicular and penile pain during arousal. Vincent could no longer have intercourse with his wife without searing pain. He called a urologist and a gastroenterologist. He scheduled appointments for both specialists around his busy schedule.
The urologist prescribed a pharmaceutical named Flomax to improve Vincent’s ease in urination. The gastroenterologist recommended Miralax, a bowel aide which allows water to be retained in the stool, thereby promoting softer stool and more frequent bowel movements. Both of these agents helped Vincent with about one-third of his overall complaints; but he was still unable to sit at his desk without pain, and his sex life had taken a turn for the worse. Vincent’s wife was unhappy, though not as unhappy as Vincent. There has to be something out there to help me, he wondered. But what?
This was when Vincent initiated his full-throttle search on the Internet. He looked for stories of men with similar complaints. Vincent lives in Central New Jersey. There came a day when he found Connect PT online. The office was merely 14 miles from his home! He booked an appointment for the following week and crossed his fingers as he paced around his office, trying to stop the throbbing in his pelvis by willpower alone.
Upon his initial Pelvic Floor physical therapy evaluation, Vincent told his entire history to his evaluating therapist. She sat and nodded, and then proceeded to ask him a series of questions about his symptoms. To every one of the questions, Vincent longed to shout: YES! I have trouble maintaining a urinary stream! I have severe constipation! I cannot sit without pain! I cannot have sex anymore, because the discomfort is not worth the release!
The PT gave Vincent some relaxation exercises, a home program to stretch his own pelvic floor and even a link to a seat cushion which Vincent could use to take the pressure off of his perineum, rectum and tailbone. This would allow him to sit for longer periods of time with less pain, the PT said. Within a few months, Vincent was able to urinate more freely, have more consistent bowel movements, and was able to return to having sex with his wife.
How had all of this happened? Was it magic? No. But it seemed that way to Vincent. Vincent’s recovery had everything to do with his willingness to seek treatment and the newfound availability of Pelvic Floor physical therapy. His symptoms were far more common than he knew. Now, Vincent writes blogs about pelvic pain in order to share his experience with other men who may be suffering from similar complaints.
The greatest outcome of Vincent’s recovery was his decision to retire from his high-stress, corporate job. He still uses the special seat cushion which takes pressure off of his pelvic floor to drive across the country in an RV. Vincent and his wife have seen Yellowstone National Park, and they even take their English bulldog named Lola along for the ride. In sum, everyone is happier. Vincent, his wife and Lola. All because of one fortuitous Internet search and the prevalence of Pelvic Floor physical therapy.
“Looking back, I see that my symptoms really began to change when I began talking about this,” Vincent says. “Giving a voice to the pain, isolation and embarrassment has changed everything. I just want more people to know that they are not alone.”
Can I do a crunch?
Written by Bryn Zolty, PT
If I just had a baby can I return to running? I’m leaking - can I do exercise that involves jumping? My doctor says I have a prolapse - can I lift weights at the gym? As pelvic physical therapists, we hear these questions every day. It is very common to wonder if after having a baby, a surgery, or if you have pain in the pelvis, if it is okay to engage in activities that can push pressure down into the pelvis.
While more research is needed to better answer these questions, there are a couple of studies available that have measured the pressure in the vagina with functional tasks, yoga poses, and other exercises in attempts to answer these questions. Here is a little of what they found with a group of women ranging in age from 20-51:
These numbers can surprise people. How can a crunch be so bad if the average pressure is 23.8 and a normal daily occurrence like coughing is 98? As a therapist, my focus is drawn to the large ranges within each activity. What is the woman doing differently to crunch at a pressure of 8 compared to the woman at a 75?
As therapists we evaluate how you move and conduct each of these activities. As pelvic physical therapists we look closer at your movement, alignment, breathing, coordination, and muscle tone in relation to the pelvis. All these factors play a role in the pressure your body places on the pelvic floor. This pressure is known as the intra-abdominal pressure. This is how one woman can have very low pressure on her pelvic floor while another woman has high pressure during the same activity. The key is how they complete the task.
Back to the question, can I do a crunch? Can I return to strenuous exercise? Our goal is to teach you how to do movements or activities properly while minimizing the negative impact on the pelvic muscles. A pelvic physical therapist’s job is to evaluate the movement or activity that gives you pain or makes you leak and improve it.
How do we do this? Let’s take a squat for example. If a patient comes in because she leaks urine while squatting, we would explore all the possibilities.
After having babies, surgeries, or injuries our bodies change. Some of these changes can lead to incontinence or pain. A pelvic physical therapist is a great clinician to discuss these changes along with your goals for fitness or everyday activities. Whether it’s cueing on alignment or movement strategies, breathing, releasing or strengthening, it is our goal to help you reach yours.
From the Glottis to the Pelvic Floor: Making Clinical Connections. Julie Wiebe, PT, MPT,BSc, and Susan Clinton, PT,DScPT,OCS,WCS,FAAOMPT.
Cobb WS, Burns JM,Kercher KW, Matthews BD, Norton HJ,Heniford BT. Normal Intra-abdominal Pressure in Healthy Adults. 2005; Journal of Surgical Research 2005; (129):231-235.
O’Dell KK, Morse AN,Crawford SL, Howard A. Vaginal Pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines. International Urogyneocology Journal, 2007;18: 1481-1489.
Did you know: nighttime urination
How Often Should I Be Peeing?
Physical Therapy Treatment: Manual therapy to hips; low back and hip stretches; posture correction; gentle abdominal and low back strengthening; home program.
Results: Left groin/hip pain 3/10 only after prolonged sitting, undisturbed sleep, 0 urinary urgency or bladder discomfort in 5 visits! No pelvic floor work necessary.
Case Study: Urinary Frequency
Physical Therapy Treatment: Biofeedback to pelvic floor; manual therapy to pelvic floor, low back, hips; posture education; hip stretching; core trunk strengthening; home program
Results: Patient voids once every 2 hours, 2x at night. Patient reports having control of urinary urgency. 0 low back pain. 10 visits!
Thinking of kicking the habit? Women who smoke are three times more likely to have urinary urgency and frequency than women who have never smoked.
(Tahtinen RM et al., “Smoking and bladder symptoms in women”. Obstet Gynecol. 2011 Sep; 118(3): 643-8.)
Did You Know: Irritating Bladder
Did You Know: Intervals for Urination