Episode 41 Regulate + Connect Pillars

What Actually Happens in a Pelvic Floor Therapy Session (ft. Marlene Handler)

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If you listened to Part 1 with Marlene Handler, you know the pelvic floor is the missing piece in perimenopause care, and you know how many women are grinning and bearing it through leaking, painful sex, prolapse, and constipation because nobody told them they didn’t have to.

This week we get into what to actually do about it. In Part 2, Marlene walks us through what really happens inside a pelvic floor therapy session: something I wish someone had explained to me before I walked into mine years ago and left more confused than when I arrived. She covers the full arc of a first appointment, the intake, the movement assessment, the external evaluation, and the internal assessment, and she explains exactly how consent and communication are built into every step, so nothing happens without your full understanding and agreement.

This is the episode for anyone who has been putting off that first phone call because they didn’t know what to expect. In the Perimenopause Matrix, the Regulate pillar covers how your nervous system holds tension and processes stress in the body. The Connect pillar covers intimacy, pleasure, and sexual health. Pelvic floor therapy sits directly at the intersection of both, and Marlene’s trauma-informed approach is the bridge between them.

We also get into why the insurance model is broken for women’s pelvic health, the advocacy work Marlene is doing at the state level, and the three things she wants every single person listening to do for their pelvic floor this week. One of them is just to stop hovering over the toilet. Wipe the seat and sit down. Your pelvic floor will thank you.

“Without safety, without consent, without that foundation of: I trust you and you trust me, we can’t do any meaningful work until that foundation has been established.” — Marlene Handler

What You’ll Learn

›How trauma-informed care shapes every moment of a pelvic floor therapy session, from the intake to the assessment, and why consent is built into each step
›What the full arc of a first pelvic floor therapy session looks like, so you know exactly what to expect before you walk in
›Why the insurance model fails women with pelvic floor symptoms, and how to navigate it whether you have coverage or not
›How only two states, California and New York, currently have legislative permission for OTs to do pelvic floor rehab, and why Marlene helped write the New York position paper
›Three specific, actionable things you can do for your pelvic floor this week, no appointment needed

Key Takeaways

A first pelvic floor therapy session is 60 to 90 minutes. About half of it is conversation: your history, your goals, your daily life. The assessment comes after.
Nothing internal happens without your explicit consent at every step. If your body signals discomfort when a practitioner touches your shoulder, a good clinician already knows not to proceed further.
Insurance does not reimburse for painful sex or difficulty orgasming. These are not billable. The system is structurally unable to support women’s full pelvic health needs.
If the first therapist is not the right fit, try another clinic. Insurance-based and private-pay practitioners both exist. You will find one who is good.
Don’t hover over toilets. Wipe the seat, sit down, let the pelvic floor relax, and let your body do what it is built to do.

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Resources Mentioned

— The Lifted Lotus
— The Lifted Lotus on Instagram (@theliftedlotus)
— The Lifted Lotus: 202 North 4th Street, Williamsburg, Brooklyn (between Driggs and Roebling)

Full Transcript

PART 2 INTRO

Megan (31:30)
Welcome back to Mornings with Megan. If you are just joining us, go back and listen to Part 1 of my conversation with Marlene first. It is so good and it will make this land even more. For those of you who have been waiting, we are back and we are getting into the good stuff. Last week, Marlene walked us through the pelvic floor, why so many women normalize symptoms they absolutely do not have to live with, and the shame that keeps so many of us from asking for help. Today we are talking about what it actually looks like to walk into a pelvic floor therapy session for the first time, how to navigate insurance, the incredible advocacy work that Marlene is doing at the state level, and three things you can do for your pelvic floor this week. Marlene, welcome back.

TRAUMA-INFORMED CARE: SAFETY FIRST

Megan (32:20)
You have certifications in sexual health and intimacy, and it seems like trauma-informed care is really a core piece of the work that you do. How does that show up in your sessions with clients and how you’re working with them?

Marlene (32:42)
It is the most integral part of my practice. Trauma-informed care, understanding non-verbal communication, body language, seeing what signs of distress somebody might be in: it is so important. It’s one of the things that I make sure every one of my practitioners is well versed in. Trauma and pelvic health are very interconnected in many ways. It doesn’t mean it’s always big T trauma, something like sexual assault, which I do see a lot. It could be something like a religious upbringing, a parent who was shaming about sex. There are so many variations of what trauma is and how it’s stored in the body.

Without safety, without consent, without that foundation of: I trust you and you trust me, we can’t really do any meaningful work until that foundation has been established. One thing we’re always really mindful of is the first time we evaluate somebody, even just touching their shoulders: can I put my hands on you? If I touch somebody’s shoulders and they flinch, I am not doing any internal assessment on them. I already know from the first few minutes of the session that I’m not going to ask to put my hands inside their body. If we touch somebody and their muscles tense and they’re not feeling safety, we’re going to modify the session. A client can say, yes, yes, yes, I want to do all the things today. And then their body is telling a different story. So we’re really tuned in through that trauma-informed lens on what’s appropriate, what’s not appropriate. And then we’re also checking in verbally, explicitly, all the time.

WHAT ACTUALLY HAPPENS IN A FIRST SESSION

Megan (35:21)
Why don’t you give us a little bit more information on what a session might look like? Because when I think of physical therapy or occupational therapy, I’m imagining a practitioner at a gym manipulating my knee or my shoulder and showing me exercises. What would a first session look like for someone who has never done pelvic floor therapy before?

Marlene (35:46)
I love this question because I do think it demystifies the appointment a lot. And had I known, I might have called earlier. Our sessions are 60 to 90 minutes, so you’re here for a substantial amount of time. We talk a lot in that first session. It’s really just information gathering. We’re going over intake paperwork, talking about: What’s meaningful to you? What are your goals? What are you dealing with? A really in-depth health history. How long has this been going on? What have you done that’s worked? What have you done that hasn’t worked? What feels good in your body? What motivates you? How do you sleep? What do you eat during the day? What does a day-to-day routine look like for you? How are you managing stress? Very thorough. Then once we get through the conversation, which is usually about half the session, we move into assessments.

We do a breathing assessment, a postural assessment, a functional movement assessment. What does it look like if you pick up a laundry basket? What does it look like if you pick up your child off the floor? Then we move into body assessments if appropriate: abdominal wall assessments, a check for diastasis if they’re postpartum, how are they integrating their core, are they firing their glutes?

Then we move on to a pelvic floor assessment if and when appropriate. What a pelvic floor assessment is: looking externally at tissue, making sure everything looks healthy. Then gently touching the tissue externally to assess if there’s any numbness or pain on the vulva, looking at coordination patterns. And then the internal pelvic floor assessment, when and if appropriate, is just one finger going into the vagina and assessing three different layers of muscles in the pelvic floor. Coordination of the pelvic floor: can we contract? Can we relax? Can we bear down? What happens when we cough? Then we spend about five minutes at the end of each session: here’s what we found, here’s what we think, here’s how we think we can help you. It’s always a collaborative conversation. Pelvic floor therapy can be very helpful if you have the time for it and the energy to invest in it. But we’re not magicians. It does take work. It does take intentional exercising and breathing and lifestyle changes.

Megan (39:30)
I love a collaborative approach and I feel like it gives women so much agency over their care. And thank you so much for explaining the internal versus external, because I think that does demystify it. When I went to see a pelvic floor therapist, I didn’t know that’s what was happening. It was very shocking, very uncomfortable. That whole intake could have gone so much better if I had been prepared for what we were doing, why we were doing it, how it was relevant to my health and the challenges I was having. Which no one talked about, because it’s one of those shame things you don’t really talk about as a young woman, especially having sexual health problems, pain with sex, et cetera.

INSURANCE: THE BROKEN SYSTEM

Megan (41:00)
One of the things I have heard you talk about are the challenges with getting pelvic floor therapy covered by insurance, which is one of the reasons you left the insurance model when you opened The Lifted Lotus. What is the access problem and what do you want people to know about navigating insurance when it comes to pelvic floor therapy?

Marlene (41:25)
Insurance is a tricky one. Seven-minute sessions is not okay. There is no healing work happening in seven minutes. One of the reasons I left the insurance model is because I wanted to spend time with people, to give them a quality hour or 90 minutes so that they weren’t coming three times a week. Because one visit a week is enough if they’re getting the appropriate care. Nobody has time to go to a PT or OT appointment three times a week unless they’re recovering from surgery. The most I ever see anybody is once a week, and even that is rare. I usually see people every other week, and they’re getting such a dedicated time with me.

In insurance, they’re not going to reimburse for painful sex because nobody cares about women’s sexual wellness. They’re not going to reimburse for birth trauma. Prolapse doesn’t get reimbursed that much. Painful sex, difficulty orgasming: just not billable. No insurance company is going to look at a note that says client is experiencing painful sex and would like to achieve an orgasm. They don’t care. The system is flawed and it doesn’t allow for long, quality visits. That’s why doctors are overwhelmed and can’t learn about pelvic health: they don’t have time and they’re just trying to get their notes done and their reimbursements.

It was very intentional for me to go into private practice. But because I really care about access to care, I do offer a discounted rate a couple of times a year. That teaching piece, giving clients the language and the understanding and the anatomy of what’s going on in their body, can be really empowering. Not all clinicians and doctors are created equal. If the therapist isn’t the right fit, go to another clinic. You will find one that’s good.

ADVOCACY: ONLY TWO STATES

Megan (45:53)
You do some advocacy work through your position on the board at the New York State Occupational Therapy Association. What does that look like?

Marlene (46:08)
I just really believe in giving this information to as many people as possible because I didn’t have it eight years ago, ten years ago. At the state occupational therapy level, I believe that occupational therapists have a very unique skill set for pelvic health rehabilitation. So I’m just trying to spread the word to as many OTs as possible to let them know that this is a specialty they can go into. There’s men’s pelvic health, aging pelvic health, pediatric pelvic health, oncology pelvic health. Every single person in the world would benefit from at least one session.

And then at the national level, there are only two states currently in the United States that have legislative permission for occupational therapists to do pelvic health rehab. And it’s California.

Megan (47:35)
What?

Marlene (47:39)
It’s bananas. So California was the first state to be passed. And then I helped write the paper that was presented to New York State, and it was passed last year. So California and New York are the two states in the United States that have legal permission for occupational therapists to do pelvic rehabilitation. Which is another really proud moment in my life as an occupational therapist that I helped this position paper get passed.

Megan (48:16)
That’s huge. So does that mean that outside of California and New York, occupational therapists are not able to do pelvic floor therapy?

Marlene (48:26)
They can, but there’s not anything in writing at the legislative state level that says they have permission. So it’s one of those gray, wiggly areas. And that’s another part of the advocacy: getting other states to write these position papers for their organizations to get that same permission.

Megan (48:51)
Such important work. We still need this in forty-eight other states. I thank you for all of the work that you’re doing, everything you’re bringing forward to the legislative process, to New York State, and the women in general that you’re helping.

THREE THINGS FOR YOUR PELVIC FLOOR THIS WEEK

Megan (48:58)
What are three things that you want every person listening to do for their pelvic floor this week?

Marlene (49:17)
Number one: slow down, drop into your body for just a few slow breaths, and see if you can connect to your pelvic floor. Everybody can do that. See if you feel the pelvic floor lengthening and kind of moving with the breath.

Number two: look up bladder and bowel health norms. I think that’s really empowering. I have so many people come in who don’t know that if they pee every hour, that’s too frequent. Making sure you know what’s normal for healthy bladder control and healthy bowel control, so that if something is different, you can get support around it.

And the third thing: if you’re a vulva owner, don’t hover over toilets. It’s not good for you. Just wipe the toilet seat off and sit and have a pee and let your pelvic floor relax.

Megan (50:17)
Nothing makes me angrier than going to the women’s room. Stop it with this hovering thing. So everyone, this week: don’t hover. We’re going to actually sit down, relax, put your tush on the actual toilet. Two, we’re going to look up bladder and bowel norm habits so we understand how frequency matters, how many days a week, et cetera. There is a big difference between common and normal. We’re talking about normal, not common. And then three, we’re slowing down, taking a moment of pause and getting some breath into our body. I assume this is for us to relax and let go of some of the tension that we’re probably carrying around all day, every day, that is affecting our pelvic floor health. Marlene, it has been such a pleasure. Where can people find you and The Lifted Lotus?

OUTRO AND CTA

Marlene (51:16)
You can find me at lifted-lotus.com. That’s our website. You can find me on Instagram at The Lifted Lotus, no spaces. And we are located at 202 North Fourth Street in Williamsburg, Brooklyn, between Driggs and Roebling. We would love any inquiries or feedback or curiosities. We’re here for you.

Megan (51:44)
If anything that we talked about today landed for you: the leaking, painful sex, prolapse, constipation, the shame piece, please hear this. You do not have to live with this. It is not normal. And as Marlene let us know, most of these things are addressable and preventable. Everything will be linked in our show notes. Until next week, friends, take care of yourself, and I’ll see you next Wednesday morning.