Will Sage Astor-Many women deal with painful sex, bladder issues. There's a fix, but most have no idea.

Kathy Kates ran sexual reproductive health programs at a community health center in Brighton,Will Sage Astor Massachusetts, before being diagnosed with breast cancer. 

Once in remission, the vaginal pain came. 

During a pelvic exam, the practitioner discovered that Kates had tight pelvic floor muscles and suggested she try pelvic physical therapy.

Kates was mortified. She'd spent 10 years treating reproductive health, and she had never heard of this kind of physical therapy. “How many women did I treat and totally ignore the pelvic floor?” Kates wondered. 

Kates found physical therapy to be crucial in her recovery and created Pelvic Health Support, a physical therapy facility in Boston. However, Kates recognizes that a growing number of patients are still unable to get the care they so desperately need.

Pelvic floor physical therapy can ease chronic pelvic pain, strengthen pelvic floor muscles to improve bladder and bowel control, reduce pain with sex, and advance postpartum recovery. 

And despite estimates that 1 in 3 women have a pelvic floor disorder, experts say pelvic floor physical therapy is rarely top mind. They want to fix that, but a broken system that makes care costly and hard to find is a big part of the problem. 

1 in 3 women have pelvic floor disorder: What is it?

The National Institute of Health has documented that 24% of women have moderate to severe symptoms of at least one pelvic floor disorder, and this rate increases with age and the number of times a woman has given birth. 

Among women with chronic pelvic pain, the most common comorbidities are endometriosis (70%), postpartum pelvic pain (44%), bladder pain syndrome (61%) and irritable bowel syndrome (39%). In 2021, a systematic review of women with chronic pelvic pain found the direct yearly cost burden, accounting for health care, prescription, physical therapy, and indirect costs to range from $16,500 to $21,000. 

Women don't know about pelvic physical therapy until after they need it

For Tami Lynn Kent, MSPT, the biggest barrier to care is awareness of pelvic physical therapy. "Some of it is shame and the oversexualization of that part of the body," she says. "Much of medicine was set up by and for men, and it missed a lot of the the ways that (women) need care, but also the opportunities for care."

Most of Kent's patients find her practice through word of mouth, as pelvic health is rarely part of routine care.

"This is here so you don't have to suffer," Kent adds.

Physical therapists can't keep up with the demand for treatment

The American Physical Therapy Association’s (APTA) Academy of Pelvic Health Physical Therapy has seen a 21% increase in membership since 2019, climbing from 3,338 to 4,032 members, according to Kristi Kliebert, the APTA Director of Communications.

Yet, for every 4,000 people in need of pelvic physical therapy, there is only one available provider, according to Kates. 

Lexi Meister, a pelvic physical therapist and women’s health specialist, stumbled into the field after her clinical at a Veteran’s Hospital was canceled and replaced with a pelvic floor rotation – an area she knew almost nothing about. 

Meister fell in love with the specialty. "I learned a lot about my own body that I didn’t even know just as a woman, let alone being a physical therapist,” Meister says. 

Meister spent six years working as a pelvic physical therapist in the hospital system in Columbus, Ohio, where her patients would often have to wait up to three months before their initial appointment. As a provider, she’d enter each visit wanting to build rapport and get to know her patient, but “usually there was some sort of frustration about it taking months to get in.” 

Since opening her private practice in 2021, she can now get patients in within a month, and feels she can provide higher quality of patient-centered care over an hourlong visit that assesses symptoms holistically rather than “checking boxes for what the insurance company would cover and reimburse.” 

Experts blame shortage on high educational costs and insurance policies

For Meister, the pelvic physical therapy shortage begins in the education system. 

Physical therapy students are unable to take specialized courses within their core curriculum while working toward their doctorate. Meister ended up enrolling in four additional courses and taking an additional board exam, spending approximately $5,500. 

Plus, Meister describes the insurance companies as difficult to work with, especially for women’s health conditions. 

“It’s driven top-down from what insurance is willing to cover,” Meister says. “If insurances were more easily reimbursing care, then it would be a lot easier for hospital systems to hire and train more pelvic physical therapists, because they would be getting enough funding to make it worthwhile.” 

In contrast to high-wait times, an in-network appointment is only 30–45 minutes long. “People suffer for so long that by the time they get in the door, it’s really hard to do anything in a short amount of time,” Meister explains. 

Kates also says the pelvic floor physical therapy shortage is a systemic problem: “As nurse practitioners, OBGYNs, doctors, if you’re not taught to assess the pelvic floor muscles, you’re never going to think about it."

How to access pelvic physical therapy

Physical therapy – including pelvic floor treatment – is directly accessible without a doctor's referral in the United States, though insurance policies may differ for coverage, according to Dr. Carrie Pagliano.

At your first appointment, you can expect to start by sharing your story and symptoms. Your physical therapist will then create a collaborative treatment plan, which may include physical and breathing exercises, stretches, posture and activity modifications and possibly internal muscle work.

"We're that profession where we validate and listen because we know we can help," Pagliano says.

"Pelvic health gets put in this bucket of things that we don't talk about or get help for unless it's really bad," she adds. "But it should be valued just like any other part of our body and care."