Ask the Expert, Sarah Macias, PT, MPT, COMT
Q&A with Sarah Macias, PT, MPT, COMT
As you may have read in a previous Q&A along with seeing Meredy Parker of Chicago Physical Therapists, I started seeing Sarah, a physical therapist as well as a breast cancer survivor. I have had a wonderful group of doctors here in Chicago and I’m so grateful. Many of them, however, couldn't relate to the rollercoaster of physical changes and emotional trauma I had been through. Sarah, however, was someone that could. It wasn’t long before I felt really comfortable seeing Sarah and talking through what my experience was and getting to a place where I could truly relax my muscles.
Thanks Sarah for the support you’ve given to me over the past few years. I appreciate you taking the time to do this Q&A with me. The questions are about the pelvic floor, dilators and breath work!
Many people with cancer simply aren’t told that treatment side effects can impact their pelvic floor. Like me, they are so grateful to be cancer-free that they don’t put side effects, pelvic floor and vaginal penetration all together. I didn’t even know what the pelvic floor was! Do you see many cancer patients?
Unfortunately this is the case for a lot of people, including myself. The early focus of treatment is on battling the cancer and decreasing the risk of recurrence. Pelvic health side effects are an afterthought, if even a thought at all. I do see many patients who are survivors, but just like you and I, they often are referred to PT - or find it on their own - for pelvic floor complaints without even understanding that their cancer treatments may have been causal in these symptoms.
I attended a breast cancer conference and when asked how many women were dry and had painful penetration since treatment the majority of the women raised their hands. Many of these women are young adults, but are also experiencing medically induced menopause with lupron or Zoladex or surgically induced menopause with oopherectomy or hysterectomy. What do you recommend for this community of women experiencing tight pelvic muscles or discomfort during vaginal penetration after treatment?
I recommend definite referral to a pelvic floor therapist as early as the patient desires. A little eduation goes a long way at prevention or management. Another intervention that can be very beneficial, but historically has been controversial, is the use of localized estrogen or bioidentical estrogen to improve the health of the vaginal tissue and pelvic floor muscles. This should be discussed with your oncologist to determine individual risk factors, but evidence supports that localized estrogen is often safe for breast cancer survivors.
In addition to pelvic floor relaxation exercises, I was introduced to dilators. What are they used for and how do they strengthen the pelvic floor muscles?
Dilators, or vaginal trainers, are plastic or silicone devices that help gradually stretch the vaginal tissue. They come in graduated sizing and are utilized from smallest to largest to reintroduce stretching and the ability to relax the pelvic floor muscles as they are inserted, effectively re-educating the muscles and desensitizing the tissues to be better at relaxing to allow penetration without pain. They do not actually aid in strengthening, but are used in instances where these tissues are tense and require training to relax.
Do you recommend women seeking out PT as well as using dilators or can women use the dilators on their own?
While dilator training is mostly performed independently and at home, it is important to first be assessed by a pelvic floor PT to determine if using a dilator program is recommended and to be trained in how to progress use of the dilators. It is important that use of dilators is comfortable and not forced, and so it is valuble to be working with a PT when initiating this treatment, to ensure that it is performed properly.
How can women approach sexual health with our healthcare providers to get a pelvic exam or other tests to identify the underlying cause and receive proper evaluation - cancer related or not?
First of all…. Recognize that just because pelvic floor symptoms are ‘common’ does not mean they are normal and does not mean that we have to just ‘deal with it’. So, if a doctor passes these issues off as normal, be your own advocate and push back. I do think it’s always a good idea to see a medical provider to discuss any concerns in order for a full medical screening, however - in Illinois, you do not need a referral to see a physical therapist (though sometimes your insurance requires it). Because of this, even if a doctor does not suggest or recommend it, it is within your ability to seek a PT evaluation anyway. The PT will do a thorough exam and be able to provide education and advice and will refer to a doctor if it is indicated and you have not seen a doctor yet.
We talked about breathing techniques during my sessions. Can you go through ones that you recommend for strengthening your pelvic floor, loosening them and helping to alleviate pain?
I recommend beginning with diaphragmatic breathing, which teaches good movement of the diaphragm. The pelvic floor coordinates with the diaphragm, and so by focusing on connecting breathing to the pelvic floor, one can improve the ability of the pelvic floor to contract and relax as it should in normal function.
How can breathing help loosen the body in general?
Deep breathing is effective in calming the nervous system by stimulating the vagus nerve. The vagus nerve is responsible for activation of our parasympathetic nervous system, which allows our body to rest, relax and digest.
For those who aren’t able to find a pelvic floor therapist in their area, can you provide a recommendation for what they can talk to their primary care or gynecologist about to get the help they need?
Many gynecologists have relationships with pelvic floor therapists that they can refer to, but it is also helpful to do your own search or talk to friends/family for recommendations. Many pelvic floor therapy clinics now have an online presence and many have the ability to do virtual sessions in cases where someone may not have access or not be able to travel.
What other issues can men and women see a pelvic floor physical therapist for?
Pelvic floor therapy can help with many conditions including: sexual dysfunction, bowel dysfunction (ex: constipation, fecal incontinence), bladder dysfunction (ex: incontinence, bladder pain, urgency, frequency), painful periods, back pain, hip pain, abdominal pain, prolapse, genital pain and much more.As a breast cancer survivor and being in the medical field what is one thing you wish you had known about regarding side effects, relationships, self-check, etc?
As a survivor and a professional in the medical field, I was disappointed to realize that many of the common side effects were not addressed until I brought them up myself. I think it was just a reminder that it is so important to stay educated, ask questions, request explanation/reasoning for treatments and always ask about possible alternatives including the risks/benefits of these. I also wish that I learned earlier in my journey about the benefits of holistic treatments to supplement my care such as acupuncture, mind-body work, somatic therapy and yoga.
Sarah has been a Physical Therapist since 2004 when she earned her degree from Northern Illinois University. She earned an Orthopedic Specialty through the APTA in 2008 and a Manual Therapy Certification in 2018 through the Manual Therapy Institute. Sarah began specializing in pelvic floor rehabilitation, pregnancy and postpartum care in 2020. She also has a special interest in cancer rehabilitation, especially following breast surgery or mastectomy.
Sarah’s career has offered her extensive experience in treating a wide variety of orthopedic conditions, having worked closely with orthopedic surgeons for more than 15 years. She values patient education and a comprehensive treatment approach, assessing the whole patient to find the root cause of their symptoms.
Sarah values a holistic approach to patient care, taking the time to understand all of the factors influencing a patient’s journey. As a 200 hour certified yoga instructor, she enjoys melding her knowledge of yoga practice with physical therapy to heal the body and the soul.
Sarah has a background in dance and enjoys staying active. She spends her free time taking road trips throughout the US, teaching and practicing yoga, biking around the city, and spending time with her family.