Healing Chronic Pelvic Pain Holistically with Lisa Costa Bir and Dr. Peta Wright

Healing Chronic Pelvic Pain Holistically with Lisa Costa Bir and Dr. Peta Wright

Dr. Peta Wright, gynaecologist and fertility specialist joins fx Medicine Ambassador Lisa Costa-Bir to delve into chronic pelvic pain. Together they look at the intricate connection between the manifestations of pain, and how this inflammatory condition is exacerbated by both internal and external stressors.

Together they explore the connections between brain-perceived exacerbations of pain, and how this has a direct effect on the presentation of this chronic and debilitating condition.

Peta shares many clinical pearls on holistic treatments of chronic pelvic pain for practitioners exploring their patient’s individual pain triggers, including the role of diet, lifestyle and underlying pathology when supporting patients to obtain and maintain long term effective outcomes.

This podcast also covers nutritional and herbal tools, hormonal treatments, and pain reprocessing therapy designed to support women in the reduction of pain while empowering them to manifest positive change.

Covered in this episode

(00:26) Welcoming Dr. Peta Wright
(05:51) Pain categories in CPP
(07:19) Diagnostics to identify the causes of pain
(13:06) Treating the whole person
(21:11) Hormone treatment to reduce pain
(24:03) Multifactorial causes of chronic pelvic pain
(28:06) Pain reprocessing therapy
(40:57) Nutrients for chronic pain management
(47:10) Herbal medicine treatments
(48:09) Benefits of a multidisciplinary approach to treatment
(53:55) Thanking Peta and closing remarks

Key takeaways

The role of hormone treatment to manage pain severity:
- The Mirena: Progestin has a suppressive effect on endometrial tissue growth via reducing blood flow, downregulating immune system activity and reducing central sensitisation.

Dietary therapies to reduce pain and inflammation:
- Omega-3 fatty acids including grass fed meat and olive oil are anti-prostaglandin
- Fibre supports estrogen metabolism and healthy bowel movements
- Ginger has been shown to be as effective as Ibuprofen when it comes to pain relief
- Curcumin to reduce inflammation
Supplemental therapies indicated in pain and inflammation management:
- Zinc
- Magnesium
- NAC
- Specialised Pro-resolving Mediators
Investigations
- Pain on most days for three months is a diagnostic tool to confirm CPP
- A thorough medical history and timeline of symptom progression
- Vitamin D status
- Laparoscopy
- Transvaginal ultrasound in sexually active women
- Pelvic MRI for endometriosis diagnosis
- Early intervention and education are key to long term management of symptoms
Fear around experiencing pain during a monthly cycle may exacerbate symptoms by dysregulating the nervous system and contributing to central sensitisation
Pain elements involved in chronic pelvic pain:
- Neuroplastic pain is derived from the nervous system or the brain
- Nociceptive pain is associated with inflammation
Pelvic floor muscle tension is a significant factor for women with chronic pelvic pain
Cognitive behavioural therapy interventions increase grey matter volume in the brain associated with reduced pain catastrophising.

Resources discussed and further reading

Dr. Peta Wright

Peta's website

Connect with Peta: Instagram | Facebook

Peta's Book

Vera Women's Wellness

Transcript

Lisa: Hi, and welcome to fx Medicine where we bring you the latest in evidence-based, integrative, functional and complementary medicine. fx Medicine acknowledges the Traditional Custodians of country throughout Australia where we live and work and the connections to land, sea, and community. We pay our respects to the elders, past and present, and extend that respect to all aboriginal and Torres Strait Islander peoples today.

With us today is Dr Peta Wright, a voice for women who want to take back their bodies and their healthcare. Peta is an integrated gynaecologist and fertility specialist with years of in-depth experience working with women across their lifespan. She's also the founder of Vera Women's Wellness and the author of Healing Pelvic Pain published in August 2023. Her philosophy is that women deserve time, space, and compassion to tell their stories and be heard, to be empowered with knowledge, to get to the root cause of their problems and supported to make the choices that feel right to them.

Hi, Peta, and welcome to fx Medicine. We're so grateful to have you here.

Peta: Thank you so much for having me.

Lisa: Oh, absolute pleasure. So, let me set the scene a little bit on what we're going to talk about today. Globally a quarter of all women report having had chronic pelvic pain for over a year. And in your book, you mentioned there seems to be an epidemic of women presenting with pelvic pain in clinic, which I certainly see in mine. You cite an incredibly interesting Australian study where they report 93% of girls and young women experience pelvic pain every month, which is huge. The majority. Why do you think we're seeing such high numbers of women with pelvic pain and what also constitutes a diagnosis of chronic pelvic pain?

Peta: So, that study I included because I don't think that that study represents a huge growing number of women with debilitating pain. It's simply to illustrate that the vast majority of women who have periods or people who have periods have some pain or discomfort with their periods for the first perhaps couple of days. And then it's usually managed with Panadol, Nurofen, and heaps of other things which we'll go into later on. And that study just shows that it's common and it reflects that inflammatory nature of a period.

So, I think sometimes the rhetoric that we hear that periods should never ever be painful actually is unhelpful because it creates a lot of fear. And as I talk about in the book, fear then promotes more pain. So, if we have people that think, "Oh, this is definitely...any degree of pain or discomfort can't be normal." Then, there are mechanisms in the body and brain that can ramp up pain.

So, I think in terms of the number of women that are presenting with debilitating pain with their periods, I think that number is increasing, although probably not reflected in that particular study. And it also is...the other group of women are women who are presenting with chronic pelvic pain, so that they're women who have pain on most days for at least or more than three months.

And then women who have debilitating period pain that is not managed with simple measures that require days off work or school or time in bed, it's really interfering with their quality of life. Either of those two situations definitely needs to be investigated and treated early because we know that pain for whatever reason that goes on unexplored and untreated. And when I say untreated, sometimes it might just be helping someone to understand what's happening in their body. And then that can reduce a lot of fear and that can reduce a lot of pain just in itself. But it definitely needs investigation and treatment because we know that that's one of the things that can precipitate ongoing chronic pain.

Lisa: Yeah. Okay. So, that's really interesting. So, chronic pelvic pain does not just have...it's not just during the period time. It literally could be every single day ongoing.

Peta: Yes.

Lisa: Yeah, and then what specific tests, if any, are used to support a diagnosis of chronic pelvic pain?

Peta: Well, there are no tests because basically if a woman comes in and says to me, "I'm having debilitating cyclical pain. I'm every single month. I'm having pain on more than most days for more than three months." That in itself is a diagnosis of chronic pelvic pain. There doesn't need to be any other test to diagnose that.

I guess what you're probably asking me is what are the investigations to find out what are the causes of that chronic pelvic pain and what tests would I do. I think it obviously depends on the person sitting in front of me, but if they were presenting with either terribly painful periods or chronic pain... And I think the other thing to understand is, well, what happens when pain becomes mostly every day. That usually demonstrates and signifies that the brain and the nervous system have become involved, and there is definitely an element of what we would call neuroplastic pain, which is pain that is derived from the nervous system or the brain.

Peta: I think it's important, when we think about pain, to break pain down into the different categories of pain. So, there are lots of different terminology that people use. So, we talk about nociceptive pain, which would be caused by, for example, an inflammatory nature of a period or inflammation relating to endometriosis. And that is pain due to those inflammatory chemicals, etc. Then, neuroplastic pain is when the nervous system becomes involved and the brain starts essentially learning pain and then can generate more pain. And the other term that people sometimes use or you might hear is central sensitisation. So, if someone is having pain on most days and not just with their periods, often we can say they've definitely got some element of neuroplastic pain and a degree of central sensitisation. It might also mean that they have more systemic symptoms. So, this is where we come to with, for example, many people will say that they might have pain with endometriosis, but they also have gut symptoms, and tiredness, and fatigue, and body aches, and pains and headache. And those symptoms we probably think are due to also that central sensitisation or inflammation in the central nervous system as well.

Lisa: Yeah, so interesting.

Peta: Yes. So, the test that I would do to figure out what's going on initially. So, I guess, look, number one, before I would do any tests, I sit down and listen to the story. And I think that's the most, most important thing kind of like doing a timeline of what's happened. And I think starting not just with the pain but starting in the beginning of the person's life, what's their environment been like. You asked me before about why do I think that pain is increasing in women. I think that, again, reasons are multifactorial, but I think that the stressors in our environment are more than ever. So, I think that exploring the environment of a person presenting with pain is extremely important. So, asking about things like family environment, adverse childhood events, which can definitely have an impact on pain, and the immune system, and the nervous system later on.

And then a menstrual history, obviously. Were periods always painful? Did they become painful? What else was happening in your life around that time? Looking at diet, looking at exercise, looking at pain behaviour, looking at beliefs around pain. All of that often will give me a very good clue about what's happening.

And then in terms of investigations, if a woman is sexually active, I would usually recommend a high-quality, highly sensitive transvaginal ultrasound that can't be done at any old place. I work just outside of Brisbane, and there's probably two or three places that I would trust to do a really good quality scan that only do women's health ultrasound and are really practised at looking for endometriosis and obviously ruling out other pelvic pathology like ovarian cysts or anything like that. So, imaging is a big one, and I think that's been... Typically in the past when we're thinking about endometriosis, most people would say, "Well, imaging can't tell us anything. The gold standard has to be a laparoscopy." We now know that imaging has actually come a really long way, and we know that a really high-quality ultrasound or for someone who has not been sexually active but I really suspect endometriosis and pelvic MRI can both be very good. And they're both probably over 90% sensitive at picking up deep endometriosis and ovarian endometriosis.

Lisa: Mm, I found that really interesting when I read that in your book, that laparoscopy should not...you don't necessarily think it should be the first line for women with chronic pelvic pain. And I think we are seeing a move away from that, but I think it's a really important point to stress for practitioners because a lot of us have been taught laparoscopy, laparoscopy, laparoscopy, but then you also mention in your book, there are women that go and have surgery and they come out and they're still in pain, which I thought was really, really interesting.

Peta: Oh, my God. I'm just doing an audit at the moment for my practice on the presentations that I see. I would say a huge proportion of the women that I see have had basically laparoscopy after laparoscopy. I went through someone's chart yesterday who'd had 10 laparoscopies, including a hysterectomy and one ovary removed, and none of the laparoscopies improved her pain.

And then they are still in pain and they've still got all of their issues. And then they've spent thousands and thousands of dollars on that.

I think the other reason is of course... I think it's highly complex. It's political as well. And I think women's pain has been ignored for a really long time, and that's not right. And I think way that in our society we validate people's pain is really through a medical, biomedical lens, right? So, it has to be a lesion or something that we can point to that we can see, that we can take out, remove, give you a pill for. Anything else is seen as not valid or dismissing a woman or a person.

And I think that has led us into a really dangerous place because out of a very valid desire for wanting to be heard and wanting to have their symptoms treated and taken seriously, we have now built up a lot of awareness and fear around endometriosis. And there is a lot of misinformation out there about endometriosis, which really increases fear, which I think leads to more pain and more presentations. And this whole early diagnosis of endometriosis being what we should be aiming for I think is actually wrong because there's actually no evidence that says early laparoscopy and diagnosis of endometriosis improves quality of life or pain. What I see is that it definitely increases the number of laparoscopies someone has in their lifetime. And let's just put our thinking cap on for one second and think, if we're doing multiple laparoscopies for something, it is not working, right?

Lisa: Yeah, and then there's scar tissue, right?

Peta: So, it's not...

Lisa: That can make things worse with multiple laparoscopies.

Peta: Correct. Yep. And you're not addressing any of the other things, and you're keeping the woman stuck in a disempowered state where she thinks that the only treatment for her pain is through something that has to be done to her, that is outside of her, that she has no control of. And it's really then you see this real identification with that illness.

Lisa: Yeah. You're quite unique in your thinking, and I almost shed a few tears when I was reading your book because in conventional medicine and even some types of naturopathic medicine, there is this emphasis on putting the body systems and the body parts into separate compartments and just seeing a woman as a person with hormonal issues. And you mentioned a story in your book, a real life scenario, where a colleague of yours heard you talking to a patient and you were addressing her, the whole person, and he said, "Oh, you're a different sort of gynae. You're like a psychologist gynae, because you were asking her about her whole being, which is very much encompassed with naturopathic philosophies is seeing the body as everything being interconnected. And I think that's a really important thing, a critical part of our patient's well-being to see them as a whole person rather than just a woman with a uterus or a woman with a vagina.

Peta: Yeah, for sure because I think the key thing with this book is I don't think...I think we really need to examine how we are siloing body parts and just doing surgeries or having a really reductionist approach to pain in the body when it is so much more complex. And we know that, and we know that from things like the fact that not everyone with endometriosis has pain. From the study that I quoted in the book where...multiple studies actually had shown that when they were doing tubal legations on women who don't have pain and they found that up to 44% of women have had endometriosis with no symptoms and no problems with fertility, they were getting the tubes tied, right?

So, this whole thing that endometriosis always equals pain doesn't compute, okay? So, also if we think logically, some of the people who have endometriosis incidentally found because the only pathway we have for managing pelvic pain is doing a laparoscopy and removing their endo. Then, is there any wonder that when we remove their endo, their pain isn't better? Because when we put our logical hat on, there must be another thing that's causing their pain. Does that make sense?

Lisa: Yeah.

Peta: And we also know there are stats that we look at chronic pelvic pain, 4 out of 10 women with chronic pelvic pain have endometriosis. Six out of 10 don't have a diagnosis of endometriosis. Again, that tells us that there's something else going on that we're ignoring. And if we continue to go down the, "You must have a laparoscopy. That's the only treatment," not only are we often not treating their pain, which is the whole point of why we're supposed to be doing it, we're also missing all of the other things that are causing pain and often re-traumatising or causing further trauma, which further fuels the fire of chronic pain.

And, yeah, it's just kind of crazy to me. And the other thing is the whole thing of when we look at the facts about endometriosis too, as I said, not all endometriosis is created equal. It's not the same beast. There's probably different pathophysiologies for different kinds of endometriosis. But on the whole, when we talk about like the majority of people who have endometriosis, 80% is a superficial endo that probably is due to retrograde menstruation. So, blood coming out of the fallopian tube and landing in the pelvis and then needing to be cleaned up by the immune system.

And to be honest, and I've spoken to people about this, who will admit that for many women, this is likely a physiological process, it's part of menstruating. And if we have a immune system that is able to cope with that, then it's okay. And the studies show this. The studies show that up to 70% of endo, if you do nothing, either goes away or stays the same. It's not progressive. So, again, there's, misinformation that, if you have it, it's always progressive. And there are women who have dreadful, dreadful, dreadful disease, but it is in the minority like 5% of women who have endo.

Lisa: Yeah, I read what you wrote in the book about that, and it blew my mind that they had a placebo kind of trial in the women that had their surgery, and then the women in the placebo, some of their endo went away and they had reduced pain and so on, which was just really interesting, right?

Peta: Yeah. So, I think there's so much that we have to critically evaluate. And I think the key, key, key thing is it's not about ignoring women's pain. No, it's about early acknowledgement and treatment of a woman's pain and education early, early. And look, I have to say, coming to this realisation as a gynaecologist who now has my own clinic and that is expensive to run, right, I used to... Because I was trained to, I would like, "Okay, someone comes with pain..." I knew enough, from talking to lots of women, and I had seen enough women in my training to know that just excising endometriosis in the main isn't effective for probably the vast majority of people. And saying that it is helpful for some women, for sure, but we need to get better at working out who those people are and giving them the option and doing all of the other things as well.

So, I used to say, "Right, you've got pain. Okay, it might be endometriosis. We should do a laparoscopy and we should do all these other things. We should do pelvic floor physio. We should look at your diet. We should look at your nervous system." And so I would do that and they would get better. But then I thought, "Are they getting better because of the surgery or are they getting better because of all the other things that I'm doing?"

Lisa: Yeah.

Peta: So, then if I've got a person who does not have any signs of deep or ovarian endometriosis on good quality imaging... So, if they have anything, they're going to have... So, if they have a normal ultrasound or a normal MRI, if they had any endometriosis, it's likely to be superficial. We know that superficial endometriosis can be physiological. We know that superficial endometriosis, if you do nothing, 40% of it over 3 or 6 months will resolve completely. I then was like, "Well, let's just do all the other things. Let's look at..." So, I can identify, "Okay, this person has pelvic floor muscle tension," which is a huge contributor to pelvic pain, which is so underrecognised and basically is the gamechanger. I think the physios who are nervous system focused have an amazing impact.

Look at diet. Look at inflammation. Look at the nervous system and the state of the nervous system. And, again, I would say as well, just like the surgery thing, if you just go supplements diet like have someone on a completely ridiculously restricted diet and give them a hundred supplements, that usually actually increases their hypervigilance...

Lisa: Yes.

Peta: ...which puts them more into fight or flight, which increases their nervous system dysfunction, which makes their gut function less well, which makes their immune system health worse, which contributes to more pain. So, it's the root cause of what is happening for that nervous system and helping to get that person to feel safe in their bodies. So, I would start to do all of that and education is a big part of that because that reduces fear. So, now I do all of those things and outlining it to that individual person, what are the factors in their story that could be contributing to their pain and address all of them. And then also I would use anti-inflammatory foods, medications, herbs, supplements, and hormones often, because, yes, again, using sometimes hormones like the Mirena or the pill. I would probably use the Mirena a lot more than the pill to be honest because it doesn't generally...

Lisa: Can I ask you why?

Peta: Why? Yeah. I use the Mirena because even though it is... So, it's about reducing inflammation, right? For someone who has a really bad flare of pain with their periods so they're having those prostaglandins released, they might have heavy periods. And when that's happening, they are having...generally, if you have heavy periods, you're having more blood back through the pelvis...through into the pelvis, sorry.

So, using something that's going to stop the period can act as an anti-inflammatory, right, because you're reducing the inflammation related to the period. And you're reducing the amount of endometrial tissue that's going into the pelvis. You're reducing the amount of work the immune system has to do each month and you're letting it catch up. And you're also helping to, kind of, reset that nervous system to give it a break, especially if it's become sensitised.

So, you can of course use the pill and just run it continuously and skip periods. The reason I use the Mirena more is because it doesn't generally turn off the cycle, and I think the cycle is really important because we need our hormones for lots of other things like bone health, and mood, and libido, and all of the other things that our estrogen, progesterone, and testosterone do. And the Mirena, it might sometimes... So, it just has progestin in it, and it works mainly locally. For the first few months of having it in, some people do stop ovulating. But then as the hormone, kind of, plateaus, most people return to having regular ovulation, which means they make the same hormones.

So, actually sometimes when I talk to a woman and they say, "Oh, it sounds really invasive. It's like something inside your body," I say, "Yeah, but it actually has way less of an effect on your whole reproductive system." The pill essentially turns off your reproductive system from your brain level, and the Mirena doesn't really do that. It really just works to thin the lining out. The progestin has a suppressive effect on the endometrial tissue, which probably has a suppressive effect on endometriosis and probably reduces endometriosis growth because of the reduced blood flow. And, yeah, it causes more amenorrhoea, so it can work well without as many of the side effects as the pill does. And that's another thing that I do. And yeah, so doing all those things, I reckon I would have... And I still do surgery.

Lisa: Yeah, I think it's really great that you're doing the surgery as well. You're seeing it. You're getting that full view of the patient from start to finish really.

Peta: But I would say that they often hardly need to have surgery when you do that approach.

Lisa: Okay. Yeah, interesting. Now with the chronic pelvic pain, we know there's a disproportionate number of women compared to men that suffer from chronic pelvic pain. It's like men still get up 1% I think compared to 99% of women. What's going on? Because men have bladders and rectums too and we know... I mean, I only found this out last year, but not all chronic pelvic pain has any pelvic disease identified, so it's crazy, right? It's called chronic pelvic pain and you just think, "Well, it's definitely going to be in the pelvis." But a third of individuals actually have no pelvic disease identified, which is kind of wild. So, what's going on there? And then also, why do men not really get it compared to women?

Peta: So, again, there was that chronic pelvic pain study that said that only 4 out of 10 women with pelvic pain had endometriosis or pelvic pathology. I think the reasons are, number one, women have more...yes, men have bladders and stuff, but they don't have an inflammatory event happening in their pelvis twice a month, which women have. Ovulation is an inflammatory event, and we make prostaglandins in order to ovulate, which is a normal part of that. And then we have our period. We also have fluctuating hormone levels, and that plays a big role because estrogen, while we need it for lots of things, it can also be pro-inflammatory. So, estrogen, like peaks of estrogen, can be related to more pain too. So, those two things from a biological perspective.

From a cultural perspective, the fact that we have these things happening in our bodies but we're expected to behave like we don't have those things happening in our bodies and we're actually expected to just carry on like... There's basically no room in society for women to be having those things. And I think that creates a lot of pressure. Even the question, oh, do you have to have a day off? If you have to have a day off, obviously that's bad and we need to do an operation or medicate you. Often women, if they were allowed to have a day off work from home and just being there, comfortable, surrounded with the hot water bottle, and that being normalised, they're not suffering. They're actually living with their cycle, which women aren't really allowed to do in our society. So, I actually think that plays a big role.

I think the impact of trauma plays a role because... So, we've talked about the impact of hormones on inflammation and our brain. We've talked about the inflammatory events that cause more nociceptive pain. And when that's happening each month, then that can predispose us to more chronic pain, regardless of whether there's any endometriosis or pelvic pathology. The cultural stuff, not making room for women. The higher incidence of childhood trauma for women, and there is higher incidence of that.

And I would say there is a higher incidence of things like sexual trauma and other things. But then on a more... Gabor Maté says that women are like the shock absorbers of society, and any group that is unable to be their authentic selves is actually carrying a lot of stress, tension, trauma in their bodies. And women as a group who aren't actually able to be their authentic selves because they have to pretend they don't have these things happening inside their bodies I think is a trauma in itself. So, I think that also perpetuates it. And then I also think that out of an attempt at trying to address this problem, all of the focus on endometriosis when, as we've said, it is a factor but it isn't the whole factor and all of the misinformation creates a fear, and that fear also drives more pain and then drives people to have a whole lot of things that they maybe didn't need to have or could have been managed in a different way. So, I think they're all of the reasons why women have more pain. There's a lot of reasons.

Lisa: Yeah, yeah. So many. And look, when I was reading the papers, I was really interested in that trauma aspect because it is something, when I'm talking to my patients about, there does seem to be a lot of that. And in the papers, they were saying 50% of women with chronic pelvic pain report a history of sexual, physical, or emotional trauma. One-third are positive for post-traumatic stress disorder.

On the flip side of that, I then was reading about cognitive behavioural therapy, and we know that pain changes the shape of the brain. On a positive side, they were showing that cognitive behavioural therapy interventions increase that grey matter volume in the brain associated with reduced pain catastrophising. So, like you said, there are so many different things we can do: talk therapy, empowerment, which I think is very important in this space, that can reduce this pain.

You talk about pain reprocessing therapy in your book. Can you talk me through a little bit more about that and how that can help women with chronic pain? I'm guessing it's what you've talked about a little bit already that the diet and the connection and things like that.

Peta: Yes. I will quickly say though... So, when you look at it as well, endometriosis and pain, when they've done studies on the extent of disease... So, this is again questioning that biomedical model, right? There is actually no correlation between the extent of the disease and degree of pain. What there is a correlation on is the presence and amount of pain catastrophisation and avoidance behaviour. And that definitely increases pain. And all of that happens when you've got a nervous system that's in fight or flight or freeze. So, it's like directly related to that programming that happens when we have developmental trauma or ongoing stress.

So, yeah, CBT can be good. Also, a lot of somatic nervous system practices are also amazing. We need to include the body and the nervous system and understanding that's amazing. So, pain reprocessing therapy is kind of like a bit of CBT pain...basically pain education. It is also somatic tracking. So, basically going into the... So, firstly, it would start with seeing your patient and then talking to them about their pain if they have... So, it's to deal with neuroplastic pain, so everyone who has chronic pain has some degree of neuroplastic pain or that brain-derived pain regardless of whether they also have nociceptive pain. So, they might have that, and then they might have also pain when they get their periods relating to that inflammation. Does that make sense?

Lisa: Yeah.

Peta: So, we're trying to deal with the neuroplastic component and so helping them to understand, "Yes, your pain that you're having every day is..." and explaining the way that happens with the brain and the increased pain pathways, that helps people to understand, and understanding means they have less fear, right? So, psychoeducation or pain education is the first part. And this is what happens with normal pain psychology too, right?

So, when they know that, and they've had or the other aspect of it is safety reappraisal. So, when they're educated that, "Okay, we've done the scans," or, "We've done the laparoscopy. There's no endo or there is, endo is removed," or whatever, there is nothing else that we need to fear about this pain. Your pain is due to the brain, the pelvic floor muscles, ongoing gut issues, whatever, all those things we can deal with, and then we go into the body and do a guided relaxation.

A lot of the time with pain catastrophisation and avoidance, it's like pushing away the pain. So, with this kind of technique, you want the person to feel safe enough to just look at the pain. So, normally I would be like, "Well, okay, you're in your body, you're breathing, you're relaxed. Now I want you to go towards that pain and observe it like you would if you were at an aquarium and you were watching the glass and you're watching all the fishes and the colours and the jellyfish and everything. Nothing's dangerous. You're just observing. You're not judging it. You're looking at it. It's okay for everything to be as it is and go towards that discomfort sensation, whatever you want to call it, describe it to me. It's safe to describe it. We don't have to push it away." And then they describe what colour, what texture, what intensity it is.

So, we give that person the safety and permission to go towards it when they feel safe. Then, we go to a different area of the body where they might feel a neutral or a positive sensation. So, it might be their breath or the feeling of the... I often do this at Vera where I work under this insanely beautiful 300-year-old fig tree. And so they're lying down. It might be the sound of the birds singing. It might be the breeze or the sun on their skin. It might be their breath. It might be some fabric that's on their clothes or whatever on their skin. And then they concentrate on that for a bit and relax into it and feel into that sensation because often when someone has become centrally sensitised, what happens is the brain becomes fixated on the pain. And even though our body is getting sensations from every part of our body all of the time, we can block certain bits out, right? But what happens with neuroplastic pain is our brain becomes hyper fixated on that area at the expense of all the other sensations in our body.

So, then often they come back...then I get them to come back to the pain and often it's either changed in some way or gone altogether. And they can practise doing that and it shows them, yes, this is your brain, or your state of your nervous system changes your experience of pain, which is proof that there's a neuroplastic component. And if they practise that, they're able to address that part of their pain story, which is a huge thing that... So, you're kind of dealing with the pain catastrophisation and the avoidance and then they can do that script at home by themselves and they can also use programs like Curable, which is a really great app which has been made by pain specialists like Alan Gordon, who was the person who came up with pain reprocessing therapy, which initially was for back pain. And it's excellent as well. So, it's a huge part of helping to dial down that central pain.

Lisa: Mm, amazing. And do you find patients are quite compliant with doing that at home?

Peta: Yes. And I think the thing is about... I mean, I prescribe probably weird things for a gynaecologist. Meditation and dance and pleasure.

Lisa: Which I love, yes, but clinically proven for pain relief, right? It's not wacky or anything like that. There's metanalysis and all this sort of stuff.

Peta: Look, I think that you can't... Everybody isn't ready, right? If there is complex reasons for pain, often pain has been there for a number of years that, firstly, I think we have to be very compassionate to people because often if you have had some autonomic nervous system dysfunction, dysregulation, which everyone with chronic pain has, why are their nervous systems in that survival mode? Because they weren't safe at a time and their body was trying to protect them, right?

So, helping someone to acknowledge that their body's actually trying to keep them safe. So, the pain is what they've learnt. And then in a way, it may have served them also in some way or it's kept them safe or it's been the thing that they've known. And it can be a hard thing to detangle. It's hard for the brain to sometimes unlearn that but it definitely can do that. It can just take time. And sometimes it can take ages, and you get an incremental improvement and then you go back until finally someone clicks. And these aren't simple, simple issues, but I feel like people who are ready and they've done all the other things. And they know that they're trying something that isn't just looking to fix one particular symptom like you're playing Wack-A-Mole like with the surgery and with the pill or whatever. You're actually dealing with the body in its entirety by starting with the nervous system, which then obviously has the flow and effect to the immune system, inflammation, gut health, pain, every area of their life, and they start to do it and they can see the differences. I think, yeah, they do so well that they keep doing it.

Lisa: They keep doing it. Yeah. I love interventions like that, and something I've been recommending more is the binaural beats. I'm obsessed with them for pain reduction and other things, too, focus and sleep. But I think low-cost interventions like these are very powerful because we can't be with our patients every day all day, and it's not necessarily easy but it's, kind of, almost pleasurable to be able to lie in bed and press play on Spotify and listen to music or do a guided meditation. And we know for example with the binaural beats, and I wonder if what you do with your therapy works in a similar way, it promotes more of those theta waves associated with deep relaxation and pain relief. And so, yeah, I just think these sorts of interventions are things patients can do themselves, and essentially they're taking that power back into their own hands, which in itself is very therapeutic and powerful.

Peta: A hundred percent. You're giving them a toolkit. Firstly, what you're doing and I think... I mean, I don't even think... I don't think I do anything. I think that my role is to help people understand their bodies, understand why their bodies are in the state that they're in through actually the cleverness of their bodies that have enabled them to survive to this point, right? And then give them with... All that knowledge then becomes power. Then you give them all these tools. And then, yeah, I think that's the work and giving them as many tools as you can. Some of those tools might land with one person, and they might not land with another. And that's why you have a variety of things to give to people in the toolbox.

I have a great binaural beats song called Sacred Om, which is excellent, and every time I listen to it, I just completely...I'm asleep within five seconds, but I'm always sending that to my patients as well. And I think that that is so empowering for them to realise that also... I think definitely the key, key, key thing, which is what I was trying to convey in this book, which is hard because it's full of so many complex things, but is that the nervous system, our emotions, what's happening to us, that alchemises in our bodies through our nervous system and changes our physiology, right?

So, it actually has physical changes that then promote those things that can lead to pain. So, it's not like saying, "Oh, you're stressed. It's all in your head." That is the opposite of what I'm saying here. It's like having this full mind-body-spirit approach actually is complete medicine rather than just, "There's a spot of something, let's cut it out." And I think even when you think about the science... And, yes, again, mouse models. Mice don't normally get endometriosis and in order to study them, they give them endometriosis.

Lisa: I know, it's horrible.

Peta: But I found this so interesting that, even if you want to be completely biomedical about it and you want to go, "Let's be so lesion-focused," the study where they looked at mice with endo, and they put one group in a cage with a cat in a stressful environment right there, and then they put some others in a really enriched environment with lots of food and lots of things to play on and stuff, and then they measured not only the endometriosis lesion weight but they measured the pain behaviour in those mice. And they found that the ones that were in the stressed-out environment had bigger endometriosis lesions and worse pain behaviour. And the ones that were in the enriched environment had smaller endometriosis lesions and reduced pain behaviour. So, even if you wanted to be totally biomedical, you can’t ignore this.

Lisa: Yeah, looking at that environment and the patient's, yeah, overall outlook on life and, yeah, their condition. So, you talk a bit in your book about favourite nutrients for managing chronic pelvic pain. Can you tell me some of your favourites?

Peta: So, with period pain, I mean, I think obviously looking at diet firstly and trying to get things in the diet. And, again, I will say that you can have the best diet and a really restricted diet. And if your nervous system is constantly in fight or flight, it doesn't matter what you eat.

But as a rule, if you want to be trying to get healthy, balanced diet with lots of . fibre, lots of fruit and vegetables, lots of omega-3s, which are anti-prostaglandins, so they can help to mop up those prostaglandins released at the time of period. Things like olive oil, reducing seed oils, processed foods, trans fats, lots of red meat. I mean, I think that some of the data shows that red meat can be associated with more pain, but there's no breakdown between grass-fed. And so I think that having good quality, grass-fed organic meat is important. But fibre is incredibly important because that helps with metabolism of estrogen and good bowel movements and things like that.

So, I would normally recommend, in terms of additions or supplements, a good omega-3. I would recommend zinc and magnesium because they both have good evidence for period pain. And I would recommend ginger during periods as well.

Lisa: I love ginger.

Peta: And there's some good studies that show ginger is as effective as ibuprofen.

Lisa: Crazy, right? It's so good. And I think it's just like three days before you start taking it, and incredibly helpful.

Peta: And less impact on the gut, obviously, than NSAIDs. So, they're my kind of go-to's. And then sometimes... So, if someone has had endometriosis or they're wanting to do more, and so I don't try and overwhelm people with a hundred things all at once. I would also check vitamin D as well because there's some evidence that low vitamin D can be associated with more higher pain experience. So, I would replace that if that was low. And then I sometimes use curcumin. I sometimes use NAC.

Lisa: Mm, with curcumin, how long would you take that for to see results generally?

Peta: Look, I used to say do it every day. And I think I've kind of moved away from... I now probably do it for a week before the period and the period itself. I think it's easier for people to follow that, and it's less expensive. So, if they have chronic pain that is not related to cycles, anything supplement-based, I would be giving to reduce inflammation I would say at least three months to see how it's going.

Lisa: Yeah, great. And you know, with the omega-3s that you use, have you tried specialised pro-resolving mediators, the SPMs?

Peta: No.

Lisa: No? No. Okay, I just found some really interesting research in endo. I mean, this is very sad. It's the mouse models again where they give them endometriosis and adenomyosis. So, not necessarily translatable into human clinical trials. And again, really looking at that lesion kind of focus, but the SPMs were showing a particular one called lipoxin 4. We know that they're anti-inflammatory and they help with pain relief. But in this study, they found that the SPMs actually attenuated aromatase expression and modified...

Peta: In a lesion.

Lisa: ...estrogen signalling, which was really interesting I thought. Again, mouse model, not sure if that will happen in humans, but just a different way of them working, which I thought, "Oh, that's something to look out for."

Peta: "Yeah, okay. That's really interesting." I haven't read that study. I will have to look into it.

Lisa: Yeah, the other one is quercetin that I find quite useful. So, again, we know it's great for reducing soft tissue inflammation but then another paper—again, not human but in vitro—was showing that it may reduce that neuropathic pain too via its ability to stabilise those mast cells. So, I think a lot of these supplements are really interesting because they're not just working on that inflammation, they're working on the nerves as well and that mast cell degranulation. And I wonder if some of them work on neuroplasticity as well like the curcumin.

Peta: Yes. So, curcumin... Exactly. So, curcumin does...when we look at TLR-4, toll like receptor 4 and we think about that model of... And obviously no one knows really about endometriosis, but we have seen in studies on both chronic pelvic pain and women with endometriosis, so women with chronic pelvic pain but don't have endometriosis also have the same upregulation.

So, when we think about leaky gut and then activation or upregulation of TLR-4, and then that increasing neuroinflammation, curcumin does work on that pathway and so does low-dose naltrexone. So, sometimes I use that as well if I've got somebody with chronic... I mean, I've tried all of the other things, and the person understands that it's off-label and all of those other things. But I've found that can actually make a huge difference as well by reducing that neuroinflammation.

PEA is another one that I used for a little bit but then actually didn't find that it was making a massive difference. I know some practitioners might find that it makes a difference, but I haven't found that it's been great with my patients. But I've also found it interesting. It's that same upregulation of that pathway that happens regardless of endometriosis or not. So, we have to treat the brain.

Lisa: Yeah, yeah. Definitely. And I like saffron and the herbal medicine for that reason too, because even though it's not a whole lot of research with saffron in pain, we know that it helps modify serotonin and that's involved with pain perception. And it works on neuroinflammation.

Peta: And mood.

Lisa: Yes, and the mood aspect.

Peta: Sometimes I use it with PMS, PMDD.

Lisa: Yeah. Oh, my favourite. Yes. I saw that you do. PMDD is one of your areas. I was very excited.

Peta: Yes. Another area that I think is also very...again, there's a huge... I just think there's this huge temptation to go, "Oh, it's the woman who's got this thing wrong with them." And there's no understanding of the environment in which this person is residing that is promoting all of this stuff that's probably really contributing to this epidemic of pain, PMDD, all of those things, and we need to address that. Women are the canary in the coal mine. That's what I think.

Lisa: Yes, definitely. All right. Now, my last question, I've questioned you to death, but in your book, you provide this really... I found it a really lovely case study on a patient called Casey. I don't know if that's their real name. So, everyone else will have to read the book. What I liked about it, and there were many, many things, but you ended up helping her find herself. And that was with part of a collaborative team. So, it wasn't just you enlisted the help of a pelvic physio, psychologist, psychiatrist, I think group peer support. And for me, it really highlighted the value of applying this team multidisciplinary approach. And so I'm wondering how important is having a team for the patient. And who do you like to collaborate with when you find yourself and, for us as naturopaths and nutritionists, where we find ourself out of our scope of practice?

Peta: I think a team is so important. That's why I created my clinic. So, basically if you've got pelvic pain, there's like a 98% chance you've got pelvic floor tension.

And most people do so well with pelvic floor physio provided that it's from a place of... Again, because we can get reductionist as well with this, we have to remember why is the pelvic floor tight because the nervous system isn't safe and the nervous system has told the pelvic floor to contract to protect itself. So, if you have an idea of going in, and just poking, and prodding, and kneading the knots out, that isn't going to help because you need to help the person feel safe that they can unwind and unfurl their muscles themselves.

So, I'm really careful about who I work with. So, I'll have a team of ridiculously amazing physios who often might not even do any physical stuff. It's a lot of... The other thing is breath. That's the other thing with pelvic pain as well in women. And this is an interesting story because often women will be just...we're taught to suck our stomachs in. When we suck our stomachs in, that contracts our pelvic floor, it contracts our diaphragm. And so many young women grow up doing this all the time. That leads to pelvic floor tension just in itself. It then leads to nervous system dysregulation because we're not taking those big, beautiful breaths that stimulate the vagal nerve. And then that pushes our nervous system more into fight or flight just from that bottom-up process, right?

And my physio was trying to teach a client to breathe properly because often just having that full diaphragmatic breath can be enough to relax the pelvic floor and really ease pain. But if women don't firstly know that their muscles are a part of it, huge part of it, then they cannot do anything about it. But the physio, again, gives them the tools to be able to do it themselves. It's not like them just working away.

And the story with this physio said she talked to this client about it and then the client went away. Saw how effective just doing diaphragmatic breathing was for her pain? When she got her pain, she was like, "I can actually make this go away just by breathing like this." And then she did a survey of people in her life. And out of the men, she said, "How do you breathe? And is your tummy sucked in or is it just relaxed?" Every woman she asked, their tummies were sucked in or the men were like, "No, what are you talking about? I don't suck my tummy in." And she came back and said to Brooke, our physio, "My God, the patriarchy has stolen breathing from us." And it's true. It's another thing that's a huge part of this, right?

So, physio is incredibly important. Dietitians, important, or nutritionists. I work with both. Naturopaths, I work with. And especially I just find naturopaths... Well, my naturopath has the best attention to detail, probably all naturopaths do and have that, again, that holistic, holistic view. I have a pain psychologist that I work with. And I also have a somatic therapist couple that we work with as well who do a lot of nervous system, and talk, and nature therapy, and creative stuff, and play, and dance, and art, and music.

And I can update you on Casey actually. It's not her real name.

Lisa: Oh, yes.

Peta: So, since the book has come out, she is now actually doing so much better. I think she has had a Mirena put in that she had put in years ago by someone else and had debilitating pain and ended up in the hospital for days and days. But we were able to do it not even under a general anaesthetic but with some good pain relief and visualisation. And before, she'd seen the physio as well who'd helped her visualise this process. So, we were able to put this in, support her during this time. Now she doesn't have a period, so she doesn't get that monthly nociceptive pain. She's done a lot of work with our somatic therapist. She's now training to run a marathon in June, which she's raising money for like the Pelvic Pain Society. She is even supporting other women who have pelvic pain in our, kind of, community and making art and is probably in the best place I've seen her. So, it's a slow burn, but it's worth it to treat the whole person.

Lisa: Yeah, oh, my gosh. So incredible and inspiring. That's a great follow-up story. I loved hearing that. Thank you so much for joining us today and sharing your knowledge. You've just highlighted so well the importance of a whole person approach to pain management and just being a practitioner and looking after our patients.

I loved reading your insights in your book where you were talking about how you got in trouble for talking to patients for too long and not meeting your KPIs. And I thank you for being so brave to change that course of your journey and help so many women as a result of what you do now.

Your book Healing Pelvic Pain is an incredible resource. I've found that it was written in client-centred language, incredibly empowering and educational, and really encourages women to be an active participant in their own health and help them advocate for themself. There's also some really good resources in the back that go into more depth with some of the key points that you've covered today. Where can our listeners purchase it if they want to?

Peta: They can get it at bookshops. They can get it a Amazon, any booksellers online. Yeah, so anyway. I just really wanted to write it because I wanted women to be able to not feel powerless, not feel like there's nothing that they could do while they're on some two-year public hospital waiting list or waiting to see someone, that there is knowledge, that their body actually...that they can have now and that is theirs and doesn't have to be...that's rightly theirs and that they deserve to have the tools. And there's so many things that they can start to do now before they even see someone. So, I just was really passionate about being able to give that to women and hoping that it might be a help in some way.

Lisa: Oh, I definitely think that shines through. Thank you so much, Peta, for joining us today.

Peta: Thank you so much for having me. I really appreciate it.

Lisa: Oh, pleasure. Thank you, everyone, for listening today. Don't forget that you can find all the show notes, transcripts, and other resources from today's episode on the fx Medicine website, fxmedicine.com.au. I'm Lisa Costa-Bir, and thanks for joining us today. We'll see you next time.

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