By guest blogger Jordan Hoffman 

Stephanie here: In the late summer and early fall of last year I began experiencing increasingly painful periods. I was bleeding very heavily, taking up to 12 Advil per day without relief, and was very concerned about what was happening in my reproductive tract. Our LA clinic opened in May and therefore I didn’t have a gynecologist here. I knew if I did they would suggest that I take oral contraceptives, which I do not tolerate, or get an IUD, which I did not want. One of my patients told me Jordan Hoffman, an LA-based acupuncturist, and this weeks guest blogger, helped her resolve recurrent yeast and urinary tract infections. I set up an appointment and expected to receive acupuncture treatments for my symptoms. Instead, we discovered some interesting things that correlated with my gynecological demise.

Our LA clinic became very busy very fast. I was eating on the run and in between patients. My diet changed in that I started eating easy, low prep things like packaged string cheese, cottage cheese, salads with cheese, yogurt, etc. I was exhausted and drinking triple the amount of coffee I used to. I was also eating chicken sausage, chicken in salad, chicken everything because it was easy.

Jordan told me I needed to take out dairy and chicken, replace coffee with tea (caffeine is okay, coffee is not) and take an individualized herbal supplement that he made for me. My first thought was that he was definitely trying to make me miserable. I love cheese, and I am from New Jersey, I have been a coffee drinker my entire life.  However, I was uncomfortable enough that I would  take this experiment on for a month and time would tell.

It worked. The next month I had NO cramps. I did not even know my period was coming. I have now been through four cycles successfully, even though I do drink one cup of coffee a day now (sorry Jordan!). This experience taught me that diet can have a profound influence on our bodies. Dietary modifications are  low-risk with possible significant therapeutic benefit. In this week’s blog Jordan will tell us why.

Okay, take it away Jordan!

Thanks Steph! Simply put: cow milk is for cows, goat milk is for goats, and human milk is for humans. Every species produces milk specific to its own species’ needs and digestive capabilities. And every species stops drinking its own milk after infancy.

Except humans.

Not only do we drink other animals’ milk but we are lead to believe from an early age: “Milk—It does a Body Good!” And yet, every day I see patients with profound and wide-ranging ill effects from consuming any and all dairy products in any quantity whatsoever. As such, ZERO dairy is the only amount of dairy that is fit for human consumption. Almond, soy and rice milks are very good substitutes.

This article is going to focus on dairy and its role in various medical conditions that may lead to or worsen pelvic pain. No matter the origin, chronic musculo-skeletal imbalances can lead to organ dysfunction and chronic organ dysfunction can certainly lead to musculo-skeletal imbalances.

Irritable Bowel Syndrome– Chronic Constipation

Irritable Bowel Syndrome (IBS) is a common catch-all diagnosis for alternating bouts of constipation and diarrhea with accompanying cramping and pain. Stress is often the default cause given to IBS. But while it can definitely play a role, stress does not cause problems alone. Rather, it exacerbates pre-existing ones. Stress plus the pathogens introduced to the gut from dairy can lead to IBS.

Dairy is a known allergen that can cause constipation, especially in children (1). You can easily do an Immunoglobulin E (IgE) blood test to check for food allergies, like to dairy. Yet, in many instances, patients have brought me their allergy tests showing no IgE response to dairy. Puzzled, I did some more research. IgE is the most likely or common immune response from our body to an allergen. But it is by no means the only response. In fact, an allergy to cow milk showing up as constipation may not even be mediated by IgE (2), revealing a less than complete picture painted by those tests.

Sixty percent of the protein content in dairy is casein, which when introduced to our digestive system becomes Beta-Casomorphine (BCM). Casein is used to make glue. Ever wonder why the logo used for Elmer’s Glue is a cow? Casein. Now notice the second part to that word: “morphine.” Just like opiate drugs, BCM can exert a numbing and paralyzing effect on our intestinal motility (3), and an analgesic and addictive response in our brain and nervous system compelling us to want more. Casein can also trigger a histamine response (4) in our intestines leading to more inflammation and irritation which can lead to more constipation.

Another aspect of dairy that can lead to chronic constipation is in its bacteria load. Pasteurization occurs at 162 degrees Fahrenheit for 15 seconds. Yet, to sterilize water we are advised to boil it at 212 degrees Fahrenheit for several minutes. There are bacteria that can survive pasteurization. In fact, the United States allows for a somatic cell count (SCC) of up to 750,000 per ml (5). Whether those cells are active pathogens like Mycobacterium Avium Subspecies Paratuberculosis (MAP) (6) or E. Coli (7), or non-active due to effective pasteurization, our immune system still recognizes them as foreign and kicks in to gear with an inflammatory response.

Inflammatory Bowel Disease

The Standard American Diet (S.A.D.) has historically placed the main focus of each meal on animal protein, and doesn’t even take into account the glass of milk on the side, the cheese along with the protein, or the ice cream for dessert. Severe inflammatory bowel diseases like Ulcerative Colitis and Crohn’s Disease are linked to the over-consumption of animal fats and the under-consumption of fiber (8), which is absent in all forms of animal protein but abundantly present in beans, peas and lentils—superior sources clean protein. Such diets can even compromise our intestinal clearance of bacteria, mentioned earlier, leading to further inflammation (9).

Hormone Dysregulation

One of the simplest ways to link food choice and the pelvis is that everything flows downhill, especially when it comes to hormones, urogenital and reproductive health. While many of our environmental pollutants can exert an adverse effect higher up the endocrine system chain at the pituitary level, the first place I tend to look for culprits is diet.

Cows are fed and bred to lactate throughout their pregnancy with particular elevated milk production in the latter half of gestation. As such, even regardless of whether they are injected with exogenous hormones, the cows’ own hormones can show up in its milk. Dairy products you consume account for 60-70% of all dietary sources of estrogen (10) with at least 6 different hormones also being found in milk, including progesterone, and testosterone (11). One way we excrete hormones from the body is through stool. Studies show that there is a direct correlation between fecal weight and fecal estrogen content (12). And with the constipating effect of dairy, we now can see yet another link between chronic digestion dysfunction and hormone dysregulation.

For men, this undue influence on their endocrine function can show up as erectile dysfunction (also an indication of atherosclerosis aided by the cholesterol in dairy), low sperm counts and ejaculatory volume (13), and testicular and prostate cancers (14). For women, this can show up as irregular and painful periods, endometriosis (15), Polycystic Ovarian Syndrome (16), and breast and ovarian cancer (17).

Where to begin

Accepting the truth about dairy flies in the face of American identity and all we have been conditioned to believe since we were kids about this primary food in the SAD. But don’t believe me and the research I have done or the results I have seen with patients. Believe yourself. Come off dairy, all forms completely. Read labels. Ask questions in restaurants. Go dairy-free for at least 4 weeks and then if you are still curious, introduce it and only it in a meal and see how you feel the next couple of days. Most of my patients will immediately feel poorly—stomach aches, sinus congestion, knee pain, etc. For some, it may only clog the arteries of their heart or disrupt their menstrual cycle, both of which take time to reveal themselves. Let the decision to cut out dairy come from your own personal experience guided by critical thinking and a willingness to experiment with self-awareness and truth.

Cheers,

Jordan

Jordan Hoffman is a California Licensed Acupuncturist, a Diplomate in Oriental Medicine and Nationally Board Certified in Chinese Herbology, specializing in Addiction, Internal Medicine, Pain Management and Nutritional and Lifestyle Counseling.  He maintains his acupuncture practice in West LA and Canoga Park, CA.  For more information, please visit http://www.JordanHoffmanAcupuncture.com.

 

 

 

 

References:

1. J Pediatr. 1995 Jan;126(1):34-9. Chronic constipation as a symptom of cow milk allergy. Iacono G, Carroccio A, Cavataio F, Montalto G, Cantarero MD, Notarbartolo A.
2. J Pediatr Gastroenterol Nutr.2010 Aug;51(2):171-6. doi: 10.1097/MPG.0b013e3181cd2653. Cow’s-milk-free diet as a therapeutic option in childhood chronic constipation. Irastorza I, Ibañez B, Delgado-Sanzonetti L, Maruri N, Vitoria JC.
3. 2000 Jun-Aug;34(3-4):181-6. Effect of opioid active therapeutics on the ascending reflex pathway in the rat ileum. Allescher HD, Storr M, Piller C, Brantl V, Schusdziarra V..
4. Int Arch Allergy Immunol.1992;97(2):115-20. A naturally occurring opioid peptide from cow’s milk, beta-casomorphine-7, is a direct histamine releaser in man. Kurek M, Przybilla B, Hermann K, Ring J.
5. Determining U.S. Milk Quality Using Bulk-tank Somatic Cell Counts, 2010. United States Department of Agriculture Animal and Plant Health Inspection Service. http://www.aphis.usda.gov/animal_health/nahms/dairy/downloads/dairy_monitoring/BTSCC_2010infosheet.pdf
6. J Food Prot.2010 Jul;73(7):1357-97. Assessment of food as a source of exposure to Mycobacterium avium subspecies paratuberculosis (MAP). National Advisory Committee on Microbiological Criteria for Foods.
7. What Is the Current Milk Quality in the U.S.? Scott J. Wells, Stephen L. Ott. Centers for Epidemiology and Animal Health, USDA-APHIS-VS. file:///C:/Users/Jordan/Documents/Research/Current%20Milk%20Quality%20in%20the%20U.S..html
8. Am J Gastroenterol.2011 Apr;106(4):563-73. doi: 10.1038/ajg.2011.44. Dietary intake and risk of developing inflammatory bowel disease: a systematic review of the literature. Hou JK, Abraham B, El-Serag H.
9. Dig Dis.2014;32(4):389-94. doi: 10.1159/000358143. Epub 2014 Jun 23. Dietary clues to the pathogenesis of Crohn’s disease. Pfeffer-Gik T, Levine A.
10. Med Hypotheses.2001 Oct;57(4):510-4. Is milk responsible for male reproductive disorders? Ganmaa D, Wang PY, Qin LQ, Hoshi K, Sato A.
11. Food Addit Contam Part A Chem Anal Control Expo Risk Assess.2012;29(5):770-9. doi: 10.1080/19440049.2011.653989. Epub 2012 Feb 14. Development of an LC-MS/MS method to quantify sex hormones in bovine milk and influence of pregnancy in their levels. Regal P, Cepeda A, Fente C.
12. N Engl J Med.1982 Dec 16;307(25):1542-7. Estrogen excretion patterns and plasma levels in vegetarian and omnivorous women. Goldin BR, Adlercreutz H, Gorbach SL, Warram JH, Dwyer JT, Swenson L, Woods MN.
13. Am J Clin Nutr.2013 Feb;97(2):411-8. doi: 10.3945/ajcn.112.042432. Epub 2012 Dec 26. High dietary intake of saturated fat is associated with reduced semen quality among 701 young Danish men from the general population. Jensen TK, Heitmann BL, Jensen MB, Halldorsson TI, Andersson AM, Skakkebæk NE, Joensen UN, Lauritsen MP, Christiansen P, Dalgård C, Lassen TH,Jørgensen N.
14. Med Hypotheses.2003 May;60(5):724-30. The experience of Japan as a clue to the etiology of testicular and prostatic cancers. Ganmaa D, Li XM, Qin LQ, Wang PY, Takeda M, Sato A.
15. Reprod Sci.2014 Oct 29. pii: 1933719114556487. [Epub ahead of print] 17β-Estradiol and Lipopolysaccharide Additively Promote Pelvic Inflammation and Growth of Endometriosis. Khan KN, Kitajima M, Inoue T, Fujishita A, Nakashima M, Masuzaki H.
16. Turk J Med Sci.2014;44(5):781-6. Insulin-like growth factor 1, liver enzymes, and insulin resistance in patients with PCOS and hirsutism. Çakir E, Topaloğlu O, Çolak Bozkurt N, Karbek Bayraktar B, Güngüneş A, Sayki Arslan M, Öztürk Ünsal İ, Tutal E, Uçan B, Delıbaşi T.
17. Med Hypotheses.2003 Feb;60(2):268-75. The experience of Japan as a clue to the etiology of breast and ovarian cancers: relationship between death from both malignancies and dietary practices. Li XM, Ganmaa D, Sato A.

For the past six months, Stephanie and Liz have been busily working on writing a book titled Pelvic Pain Explained: Everything you Need to know to Help you Navigate the Complex Terrain of Pelvic Pain. The book will be published by Rowman & Littlefield. (We don’t have the publication date yet, so stay tuned for that info!) As we’ve watched them hustle to get the manuscript together, we couldn’t help but wonder what it was that made them decide to take on the task, so we asked them!

Q. What was the impetus for your writing a book on pelvic pain?

A. Stephanie: “Very little was known about pelvic pain when I started in the field 15 years ago. Many of the patients that I saw in the early years had been suffering for at least ten years, had seen more than 20 providers, and were often on disability and opiates.

At that time I was working with a physician and we specialized solely in treating pelvic pain disorders. For this reason, my experience as a pelvic floor physical and occupational therapists was different than most. Rather than taking a continuing education course, as many aspiring pelvic floor PTs do, I was working with a pelvic pain pioneer in an interdisciplinary setting. So I found myself at medical conferences arguing that the pelvic floor muscles can be a source of pelvic pain.

Sometimes I won the argument, most of the time I lost. During this time, I also developed manual therapy skills, knowledge about medications, procedures, and surgeries. We started to figure out what would and would not work for different types of patients. Being exposed to a high volume of people with pelvic pain very quickly taught me that despite similar symptoms or the same diagnosis,  every patient was different and I had to individualize treatment plans to get them to to work.

More importantly, however, I developed clinical reasoning skills to re-work the treatment when patients either stopped responding or could not tolerate treatment. And this happened all the time. As I was developing these skills, research started to emerge and the technology boom made this information available to anyone who wanted it.

Information does not equal knowledge, however, and I had to figure out what do with patient confusion from chat rooms, being criticized by other professionals in chat rooms, and how to incorporate new diagnoses and treatment options into clinical practice. Today, it’s widely accepted that the pelvic floor muscles can be a source of pelvic pain, though many medical professionals and sufferers still do not know it.

Furthermore, we know pelvic pain encompasses much more than the pelvic floor muscles, and treatment needs to be devised with this in mind. I wanted to write this book to acknowledge the struggles patients and providers encounter, and provide knowledge to streamline the current diagnosis and treatment strategies, even in the face of a broken healthcare system. My hope is that by sharing our knowledge we will provide a platform for more effective and efficient management of pelvic pain.

A: Liz: “For years our colleagues and patients asked, ‘When are you guys going to write a book?’ I guess we finally succomed to the pressure! We’ve been teaching, lecturing, writing in professional journals for years. This was just the next logical step.

But more to the point, there are so few resources out there with good, accurate information for people suffering from pelvic pain as well as providers who treat pelvic pain. And at the same time, there is a real knowledge deficit, even among providers who should know something about pelvic pain. The number of questions we get from people from all over the world on the phone, via email, via our blog, via our website really spoke to this. We believe their needs to be one resource for people to get all of these answers. Our hope is that having this book be that resource will serve to promote awareness to the public and professional community about pelvic pain and help people get better faster.

Q: How has this blog played into your decision to write a book?

A: Stephanie: “The blog has shown me that people need reliable information on pelvic pain and made me realize that sharing our clinical knowledge allows us to help people globally. Through the comments I have learned that people are getting appropriate care but just as many are not. We need to change this and do better!

A: Liz: “We get so many follow up questions and comments with every post. Plus, we receive a  tremendous amount of positive feedback from other providers as well as patients about this blog, so for me, that reconfirmed the need for good info about pelvic pain.

Thank you Stephanie and Liz for stoking our curiosity! The next four weeks will be pretty busy as we all pitch in to get the manuscript ready to turn into the publisher, SO a handful of friends of PHRC have generously agreed to pitch in with a month’s worth of fantastic guest blog posts!

Look for them in the coming weeks!

If you have any further questions about Stephanie and Liz’s upcoming book, please do not hesitate to leave them in the comment section below.

All our best,

The PHRC Team

 

Patient History

Ted is a 67-year-old male with a primary concern of stress urinary incontinence (SUI) and secondary concerns of erectile dysfunction. Ted reports he was diagnosed with prostate cancer in September 2013 and underwent a “bilateral nerve-sparing radical suprapubic prostatectomy”, a procedure in which the nerves must be cut in order to remove the cancerous tissue, later that fall. He said he did not require radiation or chemotherapy treatment.

Ted complained of an onset of SUI after his surgery, and was referred by his urologist to pelvic floor PT. During his evaluation, Ted said he was wearing two to three pads a day with moderate saturation when changing them. He said he was “fairly” dry at night and was waking once a night to urinate.

Ted’s symptoms of SUI were aggravated with walking, standing, and an increase in intra-abdominal pressure with coughing, laughing, and sneezing. His symptoms interfered with prolonged standing and flying. He said he was “always looking for the nearest restroom”. In addition, he was unable to achieve an erection, but had a moderate erection with medication. His goal for physical and occupational therapy was to improve his incontinence.

Assessment

Based on Ted’s history, I chose to evaluate the following:

• Abdominal wall assessment for a diastasis recti, which is a separation of the abdominal muscles.
• Scar tissue assessment for mobility and hypersensitivity.
• Assessment of the transversus abdominis (TrA), the deepest layer of the abdominal muscles.
• Assessment of muscle tone in the pelvic floor musculature.
• Assessment of pelvic floor motor control.

The reason why I chose to assess these specific details was because I wanted to know if Ted’s incontinence was caused by poor integrity of the abdominal wall, scar tissue impairments, and/or pelvic floor dysfunction. These three components can often lead to SUI.

Objective Findings

Here’s what I found upon examination:

Ted had pelvic floor muscle weakness, poor endurance, as well as transverse abdominis (TrA) weakness. He could not contract his pelvic floor with an increase in abdominal pressure. Ted also presented with minimal to moderate scar tissue restrictions over his incision site and a posterior pelvic tilt of the pelvis in standing. A posterior tilt is when the front of the pelvis rises and the back of the pelvis drops due to shortened/tight muscles.

His symptoms of SUI developed due to his weak pelvic floor musculature and TrA. Low tone, or weakness of the pelvic floor muscles, can contribute to SUI with coughing, laughing, and sneezing as well as with dynamic activities such as walking. TrA weakness can also contribute to SUI because the abdominals are poorly supported. Ted’s standing urinary incontinence was due to his poor standing posture, which inhibited the pelvic floor from working properly. Ted did not have a diastasis recti.

Initial Treatment Plan

Ted’s initial treatment plan consisted of scar mobilization, pelvic floor strengthening, postural education, core strengthening, and dynamic strengthening exercises.

I worked on mobilizing the scar to increase the flexibility of Ted’s lower abdomen, and thus allow for proper contraction of TrA. This would then improve the integrity of the abdominal wall.

I gave Ted pelvic floor strengthening and endurance exercises in supine, sitting, and standing in order to increase his pelvic floor strength, and decrease his urinary incontinence. Specifically, I gave Ted the “knack” exercise which taught Ted how to contract his pelvic floor muscles in order to help prevent SUI with a cough, laugh, or sneeze.

I also educated Ted about his posture when sitting and standing in order to help place the pelvis in a neutral position, and allow for good motor control of the pelvic floor muscles. The core stabilization exercises were to help strengthen his TrA, and the dynamic strengthening exercises with pelvic floor contraction were to help decrease any SUI with walking.

Ted’s home program included self-scar mobilization, pelvic floor and TrA strengthening exercises. Lifestyle modifications included bladder retraining in order to allow the bladder to fill instead of frequently voiding to prevent SUI.

Goals

Ted’s goal to “improve incontinence” was within reason and realistic. He understood that he might not achieve complete continence, however he wanted to improve his quality of life. I felt there was room for improvement due to the low tone of his pelvic floor musculature. An increase in strength would help decrease his incontinence and improve his quality of life.

My goals for him were the following:

Short Term Goals (two to three weeks):

1. For Ted to demonstrate the “knack” exercise correctly.
2. To achieve an increase in his pelvic floor muscle strength and endurance.
3. To decrease pad usage, and to have minimal saturation.

Long Term Goals (four to eight weeks):

1. For patient to wear only one pad per day.
2. To eliminate all SUI with standing and walking.
3. No longer avoid prolonged standing and flying.
4. No longer look for the nearest restroom and to void within normal limits.

Summary of Treatment

As Ted’s pelvic floor and TrA became stronger, I progressed his exercises to a more advanced level with exercises, such as core stabilization on a foam roller. After seven months of treatment, Ted said he felt like he had plateaued, but did have significant changes.

At the time of his last visit, Ted only wore one pad per day, and was no longer incontinent at night. Ted now voided three to four times per day instead of voiding frequently, and was able to identify the difference between feeling the urge to void, versus not having an urge but still voiding due to a fear of being incontinent. Ted was no longer looking for the nearest restroom, and he was no longer anxious about flying. He also stated that he felt better overall.

However, Ted continued to have urinary incontinence with prolonged standing. We discussed other treatment options, such as a penis clamp. I also referred him back to his doctor to discuss surgical options, i.e. artificial sphincter or sling.

Ted did well with PT. Despite his continued incontinence with prolonged standing, which I believe continued to be caused by poor posture, he reported an overall improvement in his quality of life.

If you have any questions about this case study, please do not hesitate to leave them in the comments section below!

Also, And if you haven’t already, SUBSCRIBE to this blog (up top, to the right, under Stephanie’s photo!), so you can get the weekly blog update in your email inbox, and follow us on Facebook and Twitter where the conversation on pelvic health is ongoing!