Struggling with Pelvic Pain? You're Not Alone and Dr. Sonia Bahlani Has Ideas to Help
Show Snapshot:
If you've ever felt nagging bladder pressure, struggled with painful sex, or found yourself planning every outing around bathroom breaks, this episode is for you. Pelvic pain expert Dr. Sonia Bahlani combines training in both gynecology and urology to tackle the questions too many women are afraid to ask—
~What’s really causing that constant urge to go?
~ Are bladder leaks something we need to endure as we age?
~Do we have to just “live” with painful sex?
~Why does it hurt to ride a bike, wear tight jeans, do fill-in-the-blank?
Dr. Bahlani breaks down why all too common conditions are missed or dismissed, shares the latest treatment options (from pelvic floor PT to surprising medications), and offers practical lifestyle tips you can start using today. Whether you're dealing with mild discomfort or chronic pain, discover how you can start living pain-free. Bonus—learn when it’s time to see a specialist and how advocate for yourself to find the right care.
Show Links:
Follow Dr. Bahlani
Dr. Bahlani’s Book: Dr. Sonia's Guide to Navigating Pelvic Pain
Quotable:
Our pelvic and vaginal health is often indicative of our health overall. And while many like to dismiss these issues, pelvic pain is absolutely something that is treatable and manageable. You can have your life back. Don't take no for an answer.
Transcript:
Katie Fogarty [00:04]
Welcome to A Certain Age, a show for women who are unafraid to age out loud. I'm your host, Katie Fogarty. Today's show is for anyone who has ever felt embarrassed, confused, or dismissed when dealing with pelvic floor issues - you know, that discomfort, burning, stinging, sometimes pain with sex, bladder issues, even difficulty riding a bike. Today we're joined by Dr. Sonia Bahlani, who is known as the Pelvic Pain Doc. She combines gynecology and urology expertise to specialize solely in treating pelvic conditions and pain. Whether you're experiencing burning or pressure, bladder pain, or intimate discomfort that other doctors haven't been able to solve, Dr. Bahlani is here today to share breakthrough insights that could change your life. She'll tackle the questions many of us are afraid to ask, break down why these conditions are so often misdiagnosed, and most importantly, show us there's hope for living pain-free. Welcome, Dr. Bahlani.
Dr. Sonia Bahlani [01:06]
Thank you so much.
Katie Fogarty [01:08]
I am so happy to be having this conversation with you. We've covered pelvic floor issues and pelvic pain issues in the past, but it's been a while. I know from the two other times that I've shared those shows that I got flooded with direct messages from listeners talking about how they felt seen and heard. Many of them made appointments with the doctors that I featured, so I know this information is so needed, and I know you know it too because you treat women all the time.
I want to start with a quick stage-setting question, though. You have an unconventional path to pelvic floor issues and pelvic pain issues - you have both gynecology and urology training. How has this dual perspective changed your approach to treating pelvic pain?
Dr. Sonia Bahlani [01:58]
I think this approach, for me at least in treating pelvic pain, is pivotal. It's just super important because what I saw in my training - I did my OB-GYN residency at New York Presbyterian Cornell in the city - and when I was there, I saw a lot of women being tossed around from urologist to gynecologist, and they were consistently asking questions and not really getting answers. That's what stuck in my brain the most and what prompted me to do my fellowship in the Department of Urology, and then subsequently stay on in urology for academics, to do both GYN and urology, focusing on pelvic pain syndromes. They go hand in hand, and because it's just such a field that no one really does, it's important to have both aspects of it.
Katie Fogarty [03:13]
When we're talking about pelvic pain, what might a woman be experiencing when she begins to have these symptoms? Some of it's probably glaringly obvious, but for a listener who's thinking, "I do feel uncomfortable, and sometimes I have burning and stinging" - how does a woman know that she is in need of treatment?
Dr. Sonia Bahlani [03:13]
It's not always obvious, and I think that's really what's key here. I'll give you the generalized definition, and then we'll delve a little deeper. The generalized definition is pain in the abdomen or pelvis - basically anywhere beneath your belly button to your lower back - pain that exists anywhere in that area for six months. That's the definition of what we call chronic pelvic pain.
But that definition doesn't take into account the nuances of the symptoms that people might experience. It can be something as subtle as bladder pressure that continues after they void, which is not really small because it can drive people crazy once they have it.
Katie Fogarty [03:57]
I was going to say I've had that. It feels very significant when you're experiencing it.
Dr. Sonia Bahlani [04:01]
Correct. But something as nuanced as that, to symptoms like consistent urgency and frequency - peeing up to 30 to 40 times a day, waking up 10 to 15 times at night, exquisite pain, really like a stabbing, sharp pain in the vulva or the vagina or the bladder or the uterus or the rectum. And because you brought up even in the beginning about having difficulty riding a bike, that's true. Sitting for long periods of time can be difficult. It also encompasses things like painful sex or difficulty orgasming. There are so many different ways these symptoms can present, including pain with bowel movements, pain after bowel movements, pain after urinating.
Katie Fogarty [04:45]
It's so interesting to hear you spotlight all these different challenges and symptoms because I think a lot of people sometimes think of pelvic pain as being typecast to just pain with sex or bladder pain. When I researched this show, I was on your website - there are 25 or even more different symptoms and conditions that you treat. You just outlined some of them, and some of them are profound, like having difficulty with bowel movements or incontinence to a certain degree. Why do you think so many people struggle for years before getting a proper diagnosis for these pains and discomforts they're experiencing?
Dr. Sonia Bahlani [05:28]
That's one of the reasons I love doing podcasts like this. I think one of the biggest reasons is that most people are under- or misdiagnosed because these issues are so stigmatized - we don't talk about them. So a lot of people don't even have confidence in being able to discuss this with their doctors, or even when they do discuss it with their doctors, they're met with "have a glass of wine before sex" or "your pressure is not that bad" or "you could have cancer." They're met with these statements that make them think that maybe because it's not something that is life-threatening, it's not as important to treat. But these are quality of life measures, and they affect people drastically and consistently. That lag in properly diagnosing and treating someone is what causes people to suffer for somewhere around seven to 10 years before even getting a proper diagnosis.
Katie Fogarty [06:23]
It's amazing that you said seven to 10 years because in the first season of the show - I've been doing it for four years - I had a urologist who's based in New York, Dr. Angelis Kumar, come on the show. I asked her how long women sometimes wait to get treated, and she said seven to 10 years. It blew my mind to think that women would be suffering for that long before they're able to get help.
So for somebody who's listening to this show right now - some of them are already nodding their heads, like they know they have some of the things that you've just spotlighted, and some women may be experiencing minor things, like maybe that pressure, but that is still so irksome and irritating if it's interfering with your ability to just go about your day or even sleep at night - if someone's listening and thinking, "I actually want to get this investigated, I'm not waiting seven or 10 years," can you walk us through what happens in a first appointment with you? Because I think some of our listeners might be nervous about seeking help.
Dr. Sonia Bahlani [07:25]
Part of the way I structured my practice is to have a full hour with my new patients. I do that because I came from academics. When you're in medicine in general, many of us go into academics where we teach and then see patients. When I was in academics, I was asked to see patients - pelvic pain patients or urological patients - in 15 minutes, and what I realized was that you can't do that. It's actually impossible. It's actually not good for the patient and not good for the doctor.
When I was seeing these patients in 15 minutes, I couldn't understand the true sources of their discomfort because more often than not, it's multifactorial. It's often not just bladder or just pelvic floor. We're often dealing with a little bit of this and a little bit of that, and a perfect storm that kind of comes into play.
That's what prompted me to create this appointment where I have a full hour. I always tell patients, by the time they get to my office, they've often seen other providers. I say, "Bring a timeline with you. In fact, send it to me before, because I like to read that before I actually see you in the office." This is a timeline of when this all began - the ups, the downs, the nuances. The answer lies in the nuances.
I think in medicine, we're really good at putting out fires. I mean, I'm a surgeon by training. That's what we do - we're trained to put out fires. But what we're not good at doing is preventative medicine, actually scheduling a plan for someone if something was to happen and prevent it from happening. And I really think that's the wave of the future.
[SPONSOR BREAK]
Dr. Sonia Bahlani [11:04]
I would say there are a few most common reasons, but probably one of the biggest symptoms I see is a trifecta of urinary urgency, frequency, and feeling like they're not completely emptying.
Katie Fogarty [11:19]
That sounds really tricky and challenging. Why do these things come on? Is it a variety of reasons? Is it menopause? Is it structural issues? What are some of the reasons why this starts happening to women?
Dr. Sonia Bahlani [11:19]
That's such a great question. Often it's a little bit of this and a little bit of that. You know that phrase where people say - I hate this analogy, but here we are - "genetics loads the gun, but environment triggers it." So there's often this chronic inflammatory picture that can be there or not be there.
One thing that we see a lot of in terms of pelvic floor and interstitial cystitis is this concept of chronic inflammation, and specifically for something like pelvic floor dysfunction, this chronic inflammation can create what we call trigger points in the pelvic floor. When we create trigger points in the pelvic floor, your bladder contracts, and your pelvic floor spasms - it doesn't release like it should.
Think about it: if your bladder is contracting and your pelvic floor is spasming, you're not completely emptying your bladder. You're leaving a little bit of urine inside your bladder, so you're feeling like, "I gotta go, I gotta go, I gotta go," and "I always have this pressure in my bladder." But the nuance of this is that many clinicians would say, "Ah, that's bladder-based," or "You're getting recurrent UTIs, so here's an antibiotic." But the true root cause is actually stemming from their pelvic floor.
Regarding menopause - I hate saying the term "post-menopausal" because it implies that it ends right then. It doesn't. There's a transition, and perimenopause is very real, and there are a lot of clinical symptoms during that time as well, which many of us are going through in our 40s. We do know that hormonal shifts, especially with estradiol and estrogen, can shift chronic inflammatory cytokines, which can also trigger what we call subsequent flares during this time. Hormones within our vaginal and vulvar area can actually cause things like - I hate the terms we have for this - but things like atrophy or dryness, which can alter vaginal pH, which can make you more prone to infection. So it's kind of like a constellation of issues.
Katie Fogarty [13:16]
The constellation of issues makes a lot of sense to me. So let's talk through some of the options here. You mentioned antibiotics as the first line of defense - is medicine always the answer? What role does vaginal estrogen play in keeping bladder and vaginal tissues healthy and supporting the work of the pelvic floor? And then my third part of this question is, where does physical therapy play a role? So maybe we'll begin with medicine.
Dr. Sonia Bahlani [13:44]
Depending on what is happening, medicine can play an important role. But I find that a lot of people are given medicines and medications without understanding their true root cause, and that can be problematic. For example, antibiotics are definitely not first-line unless someone has a true infection that's culture-proven.
For something like pelvic floor dysfunction, I actually like to start with things like pelvic floor PT, because there is often so much that we can do myofascially with certain exercises that can actually alter people's symptoms. Then if we need to add medications at the same time - in my clinical practice, I really like to use medications like a raft. They're helpful to get you to the next stage, but I don't like over-medicating people. That's probably a pet peeve, simply because I see a lot of people over-medicated by the time they reach my office. And I'm an allopathic physician - I'm an MD, I trained in medicine and procedures, but that's just my approach to it.
Katie Fogarty [14:48]
The notion of a raft - it's a great metaphor. It can help us get to the shore and allow us to not be drowning in symptoms, but we do want to get to the root causes. So this brings us to potentially what those root causes are, and what is the role of prevention that you mentioned earlier?
Dr. Sonia Bahlani [15:07]
Root causes can really be chronic inflammation, leading to degradation in what we call the GAG layer of the bladder, or the glycosaminoglycan layer - this is known as interstitial cystitis, which can be a cause of bladder pain. You could have chronic inflammation, as we talked about before, that can lead to things like trigger points. This would be known as pelvic floor dysfunction. This is where pelvic floor PT can be really important.
Previously, you had asked about the role of vaginal estrogen, which I think is super important, because we as clinicians are often scared of hormones when we shouldn't be. Recalling the vaginal epithelium with things like topical estrogen or transdermal or systemic, just depending on the patient you're looking at, is super important. It's super important for our vaginal microbiome. It's super important for sex. It's super important, as you stated, for supporting the bladder.
And I think there's a huge role for vaginal estrogen and testosterone. To be quite frank, as women, we are often not offered testosterone. But guess what? Our clitoris is analogous to the prostate in the male - there's 70% more testosterone receptors in the vulva than there are estradiol. And to think that we're never given the option to saturate those because of our gender is just part of the reason that pelvic pain is so poorly treated in our country.
Somebody walking into your office is obviously fortunate enough to be in the hands of a doctor who is educated on these topics and understands them. How would you direct our listeners who are not New York-based, who are not going to be able to consult with you? Where would you send them to go get their initial screenings from a doctor? Is the first stop with a pelvic PT person? Is it to come to a doctor? Is it to find a urologist? Where would you direct them to begin?
Dr. Sonia Bahlani [17:21]
I would hope, with the help of what you're doing and spreading this information, that at least GYNs and primary care doctors will be open to pointing patients in the right direction. That having been said, at this point, not even every urologist is well-educated in this - I know Kelly and Rachel well, they both are excellent, but not every single person is like that.
One place that we always recommend is taking a look at the ISSWSH website. ISSWSH is the International Society for the Study of Women's Sexual Health, and oftentimes, providers on that list, which we're all a part of, most of us have done fellowships in pelvic and sexual health, and that's a great place to start because you know you're getting someone that's dedicated their career to this.
My goal, with speaking more about this, is that more GYNs and more general urologists do start to take an interest in this field, and they can be helpful as well. But I think ISSWSH is a great first stop. For menopausal patients - I hate that word, but here we are, it's all I have to use - NAMS, the North American Menopause Society, has some great resources too, with clinicians.
Katie Fogarty [18:28]
Both fantastic resources, and I'll be sure to link out to those in the show notes when this episode is live. So I want to switch gears for a minute now. We talked about some of the tools that people can use under the guidance of a trained doctor - potentially vaginal estrogen, potentially testosterone. And I know that people do want a sense of agency and control over their health.
I was also thrilled to see on your website that there are preventative measures that we can take to help prevent or mitigate pelvic pain. Not everyone is going to wind up using topical treatments - it's sort of a personal choice, it's something that they're going to walk through with their own doctor. But what are common lifestyle habits or daily activities that we could be using to keep our pelvic floor healthy?
Dr. Sonia Bahlani [19:14]
So some lifestyle modifications that we can use - number one, my three biggest tips that I give patients: First off, don't push or strain when you void or have a bowel movement. This is probably one of the most common things that I see that we don't even realize we're doing. Why is that a negative? When you push or strain, you're contracting your pelvic floor. You are increasing spasming in your pelvic floor. So while you might think that if you push or strain, you'll completely empty and won't have to go back again, what you're doing is actually causing muscle memory, retraining your pelvic floor to overly contract when it's not necessary, in fact exacerbating your symptoms rather than helping them.
Dr. Sonia Bahlani [19:14] So some lifestyle modifications that we can use is—number one, my three biggest tips that I give patients: First off, don't push or strain when you void or poop. This is probably one of the most common things that I see that we don't even realize we're doing. Why is that a negative? When you push or strain, you're contracting your pelvic floor. You are increasing spasming in your pelvic floor. So while you might think that if I push or strain, I'll completely empty and won't have to go back again, what you're doing is actually causing muscle memory, retraining your pelvic floor to overly contract when it's not necessary, in fact exacerbating your symptoms rather than helping them.
Katie Fogarty [19:56] That's so number one, everyone's going to stop doing that. What's number two? No pun intended, by the way.
Dr. Sonia Bahlani [20:05] Actually number—I know we're talking—
Katie Fogarty [20:07] About voiding and defecating, but what is your number two—your second tip?
Dr. Sonia Bahlani [20:12] On that note, number two: no constipation. Okay, make sure you're going number two. When you're constipated, what are you doing? Pushing or straining to get your stool out. Guess what muscles are involved in that? Your pelvic floor muscles, yet again. So you're building what we call hypertonicity, an over-contraction of those muscles. So people are always like, "Oh, well, okay, so you mean my pelvic floor is too tight? Ah, that must mean it's too strong." No, a tight pelvic floor is a weak pelvic floor. Think about a bicep. If you have a tight bicep, are you going to be able to lift as much? No, you're not. So it's a weak, tight pelvic floor.
Number three—and this is going to sound kind of silly, but it really, I think, works nicely—is warm baths. Heat for at least 15 minutes helps to relax muscles. When you use heat to release and relax, it increases capillary blood flow and helps with proper relaxation of muscles. So those are probably my three biggest life tips.
Other life tips I like to include: Number one, if you have a job where you sit for long periods of time—what do we talk about with pelvic floor dysfunction? We call it a disease of COVID, because my practice was booming during COVID because everyone was getting pelvic floor dysfunction from sitting for long periods of time—get a standing desk. Okay, it's a small thing, but it makes a huge difference.
Dr. Sonia Bahlani [21:58] We didn't really take a minute to go through medications for pelvic floor dysfunction. But it's not just hormones in and of itself—it's things like vaginal Valium, Botox to the pelvic floor. I mean, there are so many different things that you can do with pelvic floor PT in order to get people out of this flare and into remission.
Katie Fogarty [22:08] And so will vaginal Valium help relax the pelvic floor? What's the difference—is Botox tightening it? How do these both work?
Dr. Sonia Bahlani [22:08] Valium is a muscle relaxer, and when placed into the pelvic floor—guess what? We say "vaginal Valium," but you can actually place it rectally, and it works better rectally. And men can also get pelvic floor dysfunction, and they only have, by all means, one hole that you can place the medication into. So it's not just vaginal—it could be vaginal or rectal. Valium helps to relax the pelvic floor. So when you're doing pelvic floor PT, and they're doing something that's called myofascial release, where they take their finger and they put it on a trigger point and release it, and you use a medication like Valium, it helps to create muscle memory in a relaxed state for the pelvic floor.
Katie Fogarty [22:46] Is this something that we have to do till the end of time? Or do we retrain our muscles so that we can then stop with these interventions and just sort of allow better voiding habits to help us keep the trains on the tracks?
Dr. Sonia Bahlani [23:03] Exactly. No, I do not like to be putting Botox in every three months. So number one, I use Valium like a surrogate marker, like diagnostic and therapeutically. If someone responds to Valium suppositories with PT, guess what? Our hypothesis of pelvic floor dysfunction is spot on. I don't like people on Valium for longer than three months, simply because it is a benzodiazepine, and there can be—you don't want to become dependent on it by any means.
So if that works as a surrogate marker, we do something that's called Botox to the pelvic floor. Botox is a medication that is used for wrinkles, for migraines, for TMJ—it works at the neuromuscular junction, for a molecule that's called acetylcholine, and helps muscles to stay relaxed. The point being that if we put Botox into the pelvic floor, and someone does pelvic floor PT, and they get relief for three months, they're able to retrain their pelvic floors so that they don't need to consistently have PT or consistently be on medications—their muscles now remember the more released steady state. And then, of course, things can cause flares that make you go backwards, but oftentimes, some people are able to go into remission and not see me again.
Katie Fogarty [24:17] That is great news, and three months is something that's probably manageable for anyone who's experiencing this. What is the onset of these issues? I mean, my listeners are in peri and in menopause, post-menopause—does this happen at any age, in any stage? Are there certain kind of catalysts that might kick some of these problems into gear?
Dr. Sonia Bahlani [24:42] I would say that it really is so individualized, but having said that, there are certain things that can kick-start this. So I'll give you an example. I don't really say this on podcasts, but I feel like we're having a good conversation. We've already—
Katie Fogarty [24:57] Made number two jokes, so you're allowed to say whatever you want, Dr. Bahlani.
Dr. Sonia Bahlani [25:02] When I was learning this field, I actually went to see a pelvic floor physical therapist, because I thought, "I want to know what they're doing there." And I didn't just go to see one—I took an algometer, which is a pressure sensor with a wand. So I was like, when they examine me, I want to know what my pressures in my pelvic floor are.
So I go see the pelvic floor physical therapist, and she puts the wand in, and she looks at the algometer, and she goes, "Dr. Bahlani, your pressures are really high. You have pelvic floor dysfunction." And I said, "What?" No, I was in my 20s, you know, I was doing my fellowship. I'm like, "I'm completely asymptomatic. I have no issues with any of this." And I had my second kid, and, you know, I had shifts in hormones and stuff like that. And I started to develop some urgency and frequency. My point is—things can lay latent for years and years and years, and then there's something that adds fuel to the fire that tips that cup, that creates this, what I call cycle. And the cycle is what keeps people in pain.
Katie Fogarty [26:08] Thank you for sharing that story. In the spirit of total transparency, I also worked with a pelvic floor therapist. I was having urgency and frequency as well. You know, I have three kids, and this was probably well after I'd had my third baby, but I'm like—we had, like, a family joke that my husband's family comes from camels, like he never needs to go to the bathroom on eight-hour drives, and I need to stop at like every other rest area.
And finally, I was getting annoyed with myself, and I went to the woman, and she was terrific, because she did some stuff. There was tightness on one side. We had some exercises that worked. But part of what she just sort of solved for me is she said, "The reason why you think you have to go to the bathroom all the time is because you're going to the bathroom all the time. Stop doing that. Train your bladder to go a little bit longer," and it was like a light switch.
I don't know that I would have made that transition on my own, but it made a huge difference. And I'm not getting up in the middle of the night anymore, and I'm going every five exits now—only kidding, but it definitely made a huge difference. And, you know, like I joke, I can sit in the middle seat of the airplane now without having a panic attack. So I think it's so important. These are small quality of life issues, but they can also be massive quality of life issues for women that are suffering, and creating the show has taught me that too many women suffer for far too long.
We're nearing the end of our time, but I do not want to let you go without asking you this. I mean, you have treated literally thousands of patients over your career. What is the biggest, most important message that you want to share with somebody who's sort of losing hope about what's going on with their pelvic floor health and their pain?
Dr. Sonia Bahlani [27:54] The biggest message that I want to give to anyone who's suffering is that our pelvic and vaginal health is often indicative of our health overall. And while many like to dismiss these issues, I would say it's absolutely something that is treatable, that is manageable, and you can have your life back. And so don't take no for an answer. Seek care. There are providers out there, many of whom you've mentioned, who have dedicated our careers to this. And there is absolutely hope and light at the end of that tunnel.
Katie Fogarty [28:31] Such a great message. And I would also say everyone needs to go check out Dr. Bahlani's website, even if you do not live in the New York area, because she has a very comprehensive list of what it is that she's able to help patients with, and you might see yourself in that list, and then better understand that there is help out there. So how can listeners follow you? Find your website, which I just got them excited about, follow you on Instagram, where you also share a lot of great information and resources?
Dr. Sonia Bahlani [29:00] Thank you. So I'm really passionate about educating and I even wrote a book. It's called "Dr. Sonia's Guide to Navigating Pelvic Pain." You can find it throughout Amazon, Barnes & Noble, whatever. So I think that's a good resource for people who are not New York-based either. My Instagram handle is @pelvicpaindoc, my website is www.pelvicpaindoc.com. I'm located in the Upper East Side of Manhattan, and you can always give the office a call at 212-634-9533, even if we can't see you, we can help try to direct you in the right direction.
Katie Fogarty [29:35] Fantastic. Thank you so much. I'm putting that all in the show notes for all of our listeners. If you're experiencing any kind of pelvic pain, floor discomfort, remember, you do not need to live like that. You do not need to take no for an answer. The help that you need is out there. Thank you so much for joining me today, Dr. Bahlani.
Dr. Sonia Bahlani [29:52] Thank you for having me. This was so fun.
Katie Fogarty [29:56] Beauties, what a fantastic conversation. This is exactly why I created A Certain Age podcast—to have these kinds of conversations, to talk about the types of topics that too often get swept under the rug. Midlife is more fun when you're hanging out with friends, when you're hanging out with experts who get you, when you're getting the information that you need, the tools that you need to thrive.
Please share this show with the women in your life. I think this episode is too good to keep to yourself. Thank you for sticking around to the end. Thank you for all the smart and thoughtful questions that have been coming in all year long. I am excited to be answering listener questions on the show. So if you have one, email me at katie@acertainagepod.com. Feel free to come over and hang out on Instagram @acertainagepod—you can DM me your questions there. I want to hear what's on top of your mind.
Thank you for listening to today's show, for sharing with your friends, for hopping on over to Apple Podcasts or Spotify to write me a review. Reviews really matter. Not only do they make me feel incredible—I love reading them—but they also help other women find the show and help the show grow.
Special thanks to Mike Mancini, as always, who produced and composed our theme music. See you next time, and until then, keep on aging boldly and aging out loud.