A celebration of liberating women's mysterious "down there" to everyday science and healthcare

If you're in women's health, strange things make your year. One was when women's pelvic medicine finally emerged from thousands of years of medical darkness into just another solvable set of issues.

In our newest Clinical Connections post, we have the usual context below, as well as additional information on pelvic floor centers and how to find a pelvic floor specialist. If you’d rather skip right to the podcast and a related article, here you go:

• From Substacker Dr. Kelly Casperson, “Urogynecology Exists For Things We Don't Want To Talk About,” a podcast interview with Dr. Jocelyn Fitzgerald, a board-certified subspecialist in urogynecology and reconstructive pelvic surgery.

• Birth: “Is it better to tear than have an episiotomy?,” an article Dr. Fitzgerald published, is the most objective I’ve seen (and I know something about this¹). I’d add that if someone you love is expecting a baby, make sure her yoga or prenatal classes include pelvic floor prep for birth, and let her know about pelvic floor therapy after birth. Helping her now can prevent myriad problems later in life; she’ll thank you.

Modern pelvic floor medicine history

(…according to mag; other accounts may differ. What’s been your experience?)

Female pelvic medicine and reconstructive surgery (FPMRS) didn’t become a fellowship-trained, board-certified medical subspecialty² until 2013. In the decade before, rare fellowship-trained FPMRS physicians were s.l.o.w.ly emerging from academic centers into the wilds of healthcare.

For those of us in women’s health, it was like light breaking through the clouds after Noah’s storm.

For thousands of years before then, healthcare providers had been fumbling around in women’s mysterious parts, looking for leaks and other oddities, kind of like…well…plumbers in a crawl space armed with a big multifunction tool.

Both women and men spring leaks, but I suspect women talk about it more among themselves. After all, unlike men, we think it’s perfectly normal to make new BFFs in public restrooms. And leaks are just so common. As many as a third of women in their 30s spring leaks “down there,” as do 80% of women over 65, and about 50% in between those ages. (Note “80%” makes leaking the norm, not some disastrous, unusual, embarrassing female malfunction.)

In the mid-2000s, I sponsored seminars entitled “What’s up down there?" to the discomfort of many in the health system where I was a VP. Administrators might have been uncomfortable, but women showed up by the hundreds, standing in line to get information. The demand was there; really good professional help and empathy too often were not.

Most of those women ended up in a urologist’s office. Nothing against urologists; we absolutely need them. But if you scan urologist websites, you’ll find more key words about men’s healthcare than women’s: male reproductive organs, penis, scrotum, prostate, male sexual health, erectile dysfunction, male infertility, vasectomy, sperm cryopreservation, and on and on.

It’s not a defect; it’s just the air they breathe. In 2000, only 8% of urologists were female. By 2024, that percent had risen all the way to 12%.³ While intent and interest make a difference, the known is an easy default. That’s not new; it’s been the case for a long time. Hippocrates, alarmed 2000 years ago at the presence in women’s bodies of a strange organ (AKA not found in men), proclaimed the hystera⁴ (uterus), wandering around in women’s bodies, was the cause of women’s diseases and, of course, women’s un-male emotions. You know…hysteria.

Bottom line: throughout history, (predominantly male) doctors have considered women’s bodies an atypical warp of the norm (men’s bodies). Nothing new there. (Some would say we’re headed back there again…but I digress.)

Women’s leaks were often treated as an odd aberration from men’s plumbing. With horror now, I can remember my mother going through urology procedures in what looked like a rubberized alien torture chamber. Back then, women often experienced massive pelvic trauma as a direct result of the medical interventional childbirth practices of the era. They were then handed off by the same obstetricians who’d cause the damage to urologists—men who arguably were even further away from being able to relate to what the woman were going through.

But then, with FPMRS, we finally had physicians who spent an extra three or more years of their lives in a comprehensive pelvic floor fellowship. OB-Gyns started the focus on pelvic floor specilialization, joined by some urologists (often female). The fellowships—looking at the role and function of the entire pelvis—took women’s “down there” problems from 1D to 3D overnight. Much more than just the bladder and urethra were involved, and these physicians understood that.

Urologists, left watching OB-Gyns launch the new subspecialt , saw the move as a hostile takeover of the female pelvis. Marketing battles followed. But by 2023, the two specialties mostly made up⁵, and in 2024, the subspecialty was renamed from “Female pelvic medicine and reconstructive to surgery” to “Urogynecology and Reconstructive Pelvic Surgery.”⁶

There are still fewer than 2,000 of these subspecialty-trained physicians available in the US. Many common pelvic or bladder issues can be handled by either an OB-Gyn or urologist, but if you aren’t improving or your questions aren’t answered, it’s absolutely worth seeking out a subspecialty-trained physician. No one physician can know everything, and the more education and experience, the deeper the knowledge of options and treatments.

To find a urogynecologist in your area, search “urogynecologist” (and/or “female pelvic floor doctor”) and your metro area. Don’t depend on national database searches which are often not up to date or may be for-profit, dependent on physicians paying to be included. But do check after you find one to make sure they are fellowship-trained and board certified as a urogynecologist. The subspeciality has become popular enough that some claim it without the training. When I’m researching these physicians, I also check to make sure they did a fellowship, and look at physician satisfaction ratings on independent websites like HealthGrades and others, not just practice data.

• Check your doctor’s training and certification here.

• Find an APTA-certified pelvic floor physical therapist here.

And it isn’t just leaks, and definitely not just surgery

These physicians help with much more than leaks. They’re experts in congenital anomalies of the reproductive tract, fecal incontinence, pelvic organ prolapse, fistulas, chronic constipation, complications from prior surgery, and pelvic pain—a huge issue. Click for more here and here.

IMO, one of the biggest advantages of taking a holistic view of the pelvis—not just the urinary system—is that it also brought terrific non-surgical interventions. Most urogynecologists take a team approach. In addition to the urogynecologist, in pelvic health centers you’re likely to also find colon and rectal surgeons, and a full range of non-surgery therapies like biofeedback, related lifestyle and nutritional counselling, a wide (and growing array) of medical options, and a strong focus on pelvic floor rehabilitation and PT.

Multidisciplinary pelvic health centers like this one at UCSF in San Francisco or this one at Columbia in New York are increasing nationally as these subspecialists become more available. Previously, there were so few they were often only at academic centers. It’s easier now to find board certified or eligible urogynecologists in private practice or affiliated with health systems in larger metropolitan areas.

Bottom line: For someone who’s been involved since the pelvic health dark ages on this, I can’t tell you how great it was to see this interview on Substack! We all have a pelvic floor that’s doing amazing daily duty; it’s terrific we’re finally talking much more openly about keeping it healthy.

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1. Among my many former professional lives, the most immediately rewarding was when I was a practicing certified nurse-midwife (CNM). Episiotomies occupied a lot of our clients’ thinking then, and it took a long time for actual data to overcome a handy pair of scissors and the inclination to speed things up—to do something—usually much less of an issue among midwives than physicians at the time.

2. A fellowship is additional subspecialty training in medicine, usually another 2-3 years of highly focused training. That follows 4 years of pre-med, 4 years of medical school, and 3-4 years of residency to become a specialist. Yes…15 years of their lives given up to get to that goal. That’s commitment, so be thankful they did it. Many subspecialists are in their mid-thirties before they can begin a practice, finally earning a living, not just medical education debt.

“Board certified (BC)” means the physician has passed a rigorous examination (“boards”) in their area of expertise. “Board eligible (BE)” means they have finished their training and are in the process of caring for the requisite number of people (“cases”) to take the boards. At the specialty level and above, BC or BE is a basic requirement to join a hospital staff in all but some of the most rural US hospitals. There is also usualy a time limit to move from BE to BC.

OB-Gyn and urology are “specialties.” Fellowship-trained pelvic floor doctors discussed in this post are actually “subspecialists,” although the public tends to lump both specialists and subspecialists together as “specialists.” One big difference between specialists and subspecialists: there are many more of the former than the latter. That’s why you’ll generally find subspecialists like pelvic floor physicians centralized at health system hubs, not out in the suburbs. While there are about 44,000 board-certified OB-Gyns in the US, and 14,000 urologists, there are currently only 1,700 doctors BC/BE as urogynecology and reconstructive pelvic surgery subspecialists. IMO, if you’re having persistent problems to which you’re not finding an answer, travel is a non-issue. We only have one pelvis, and it’s the key to so much else in our lives.

3. If you think male-dominated businesses can be brutal to women, you haven’t seen anything until you see how a male-dominated medical specialty can treat female residents. If you go to a female urologist, ask her for stories; she’s likely to have some doozies.

4. 2000+ years ago, and everyone’s still stuck on the hys: hysterectomy and, of course, hysteria—the “too emotional” (AKA not-male) label that hangs steadily with us today from the board rooms to our homes. Hippocrates should be proud; 2000 years is a long time for a name to stick around on anything.

5. There’s not yet a combined national website or search engine. It’s stil early days after the January 2024 name change, but it sure would be useful.

6. Seriously? Neither name was consumer-friendly. Obviously, no one thought to involve marketing professionals—specifically branding experts—in the naming of either. In healthcare, we remain cautious about involving the dark side (marketing), and we adore long names and acronyms that mean nothing to the public. Maybe by 2034 we can come up with a name people can actually remember.