According to the International Menopause Society, “The purpose of the day is to raise awareness of menopause and the support options available for improving health and well-being.” While we have come a long way in bringing this issue into the spotlight, I still encounter patients on a daily basis who are unaware of what this transition can mean to their long-term health and quality of life. Some do not discuss their symptoms with their physician, and others, despite sharing their symptoms with their doctor, often leave the visit with “just live with it” as the recommended course of care due to fear of breast cancer (Barber and Charles 2023).

I have been teaching my menopause course, Menopause Transitions and Pelvic Rehab, for almost three years. A common question raised by participants during the course is whether discussing hormonal treatment options is outside the scope of pelvic rehabilitation. While I understand the concern, I do have some thoughts I would like you to consider. To elaborate, let me share a recent clinical experience I had when evaluating a patient for an orthopedic pathology.

This patient was a cis-female patient in her late 40s who presented to the clinic for mid-back pain. She had an extensive medical history of auto-immune conditions and work-related injury. She had been hospitalized due to her diagnosis and had lost a substantial amount of weight. As with any therapy evaluation, I asked how she was sleeping.

What she reported isn’t atypical for many of my patients. She was having pain that was disrupting her sleep patterns. She also reported hot flashes that were waking her up frequently in the night. She would go on walks occasionally but was not exercising regularly due to fatigue. Her food intake consisted of several servings of vegetables and fruit but was lacking in protein. On further discussion, she reported not having a period for a little over a year. She had misgivings about hormones due to breast cancer risk and wasn’t sure it was an option for her.

I was able to explain the background behind the Women’s Health Initiative and how this research was misinterpreted in the media and among many in the healthcare community regarding the safety of hormone therapy (Bluming and Tavris 2018). I explained estrogen is approved for the treatment of hot flashes and prevention of osteoporosis by The Menopause Society (position statement 2022). I also discussed the current recommendations of weight training from the Center for Disease Control of two days a week. We strategized goals for implementing this into her plan as she progressed in her exercise ability. I highlighted how the ability to process protein diminishes as she ages (Bauer et. al, 2013) requiring diligence to ensure adequate amounts in her diet.

On her next visit, she reported meeting with her obstetrics and gynecology doctor. She was given the option of hormone therapy and had started on a daily regimen. Her sleeping had improved, and she was feeling more like herself. She was making an effort to get protein at every meal, and while she was still not exercising consistently, she was hoping to start soon.

This patient was at high risk for osteoporosis due to her substantial weight loss and low BMI (Xiang et. al, 2017). Her sleep was being impacted by her hot flashes. Lack of sleep has been shown to increase the risk of cancer, heart disease, and neurodegenerative disease (Garborino et.al, 2021). It can also affect our patient’s ability to cope with stress and pain. How is someone supposed to heal if they can’t sleep? If I had not known about approved hormonal medications for the symptoms the patient was experiencing – I would not have been able to explain this option to the patient.

As pelvic health therapists, prescribing medications is certainly outside our scope. However, if we aren’t aware of their indications, how are our patients supposed to know their options? We are often the health care provider in whom they spend the most time and thus our patients often report symptoms to us that they haven’t shared with their doctor.

That is not to say that patients do not talk to their doctors about menopause. Many patients do actually report their symptoms to their physician; however, studies have found that these physicians often have not received the proper education on the menopause transition and are not always aware of when to prescribe hormone therapy (Kling et. al, 2019). We can provide referrals to specialists who DO have that knowledge so patients can know their options and make decisions together with an informed provider.

We can help to bridge the knowledge gap by knowing risks, benefits, and treatment options, not for prescription of medication, but as a conduit of information to give our patients options to discuss with their providers. This can allow for symptom management, improving quality of life, and in some instances prevention of fracture.

The more healthcare clinicians that have a basic understanding of menopausal symptoms and treatments, the more patients can be made aware of the options available to them. This allows for a dialogue to occur between physician and patient. Certainly, this is only a small piece of the treatment puzzle. There are many more important aspects of treatment including building muscle, sleep hygiene, stress management, and nutrition, which do fall within our scope.

In honor of World Menopause Day, let’s celebrate by raising awareness for our patients in regard to this change, and what can be done as they navigate through this transitional time. Join me on November 2-3, 2024 in Menopause Transitions and Pelvic Rehab to be a part of the conversation. 

References:

1. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022. 29(7): p. 767-794.
2. Barber, K. and A. Charles, Barriers to Accessing Effective Treatment and Support for Menopausal Symptoms: A Qualitative Study Capturing the Behaviors, Beliefs and Experiences of Key Stakeholders. Patient Prefer Adherence, 2023. 17: p. 2971-2980.
3. Bauer, J., et al., Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc, 2013. 14(8): p. 542-59.
4. Bluming, A.Z.T.C., Estrogen Matters. 2018, 1290 Avenue of the Americans, New York, NY 10104: Little, Brown Spark. 310.
5. Garbarino, S., et al., Role of sleep deprivation in immune-related disease risk and outcomes. Commun Biol, 2021. 4(1): p. 1304.
6. Kling, J.M., et al., Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey. Mayo Clin Proc, 2019. 94(2): p. 242-253.
7. Xiang, B.Y., et al., Body mass index and the risk of low bone mass-related fractures in women compared with men: A PRISMA-compliant meta-analysis of prospective cohort studies. Medicine (Baltimore), 2017. 96(12): p. e5290.

AUTHOR BIO
Christine Stewart, PT, CMPT

Christine Stewart, PT, CMPT (she/her) graduated from Kansas State University in 1992 and pursued her master’s degree in physical therapy from the University of Kansas Medical Center graduating in 1994. She began her career specializing in orthopedics and manual therapy then became interested in women’s health after the birth of her second child.

Christine developed her pelvic health practice in a local hospital with a focus on urinary incontinence and prolapse. She left the practice in 2010 to work at Olathe Health to further focus on pelvic rehabilitation for all genders and obtain her CMPT from the North American Institute of Manual Therapy. She completed Diane Lee’s Integrated Systems Model education series in 2018. Her passion is empowering patients through education and treatment options for the betterment of their health throughout their lifespan. She enjoys speaking to physicians and to community-based organizations on pelvic health physical therapy.

Tara Sullivan instructs her course Sexual Medicine in Pelvic Rehab on October 19-20. Her course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions of all sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Menopause is a natural phase in a woman's life, signaling the end of her reproductive years. While many are familiar with common symptoms such as hot flashes, night sweats, brain fog, and mood changes, there is another less-discussed condition that affects many women: Genitourinary Syndrome of Menopause (GSM). GSM encompasses a range of symptoms affecting the genital and urinary systems, profoundly impacting a woman’s quality of life. Understanding GSM is crucial for women entering menopause and healthcare providers, especially pelvic floor specialists.

What is Genitourinary Syndrome of Menopause (GSM)?
Genitourinary Syndrome of Menopause (GSM) refers to a collection of signs and symptoms associated with the changes in estrogen levels that occur during menopause. These hormonal changes affect the tissues of the vulva, vagina, urethra, and bladder, leading to a variety of symptoms that can be both uncomfortable and disruptive.

GSM was formerly referred to as vulvovaginal atrophy, but this term was considered limited because it didn’t encompass the full scope of symptoms women experience, particularly those related to the urinary system. The term "GSM" is now preferred as it better reflects the diverse nature of the condition.

Common Symptoms of GSM

1. Vaginal Dryness and Irritation: One of the most frequently reported symptoms of GSM is vaginal dryness. This occurs because estrogen levels drop, causing the vaginal tissue to become thinner, less elastic, and less lubricated. This dryness can lead to itching, burning, and irritation. 

2. Painful Intercourse (Dyspareunia): Vaginal dryness can make sexual activity uncomfortable or even painful. Women may also experience tearing or bleeding during intercourse due to the thinning of the tissue specifically around the vaginal opening.

3. Urinary Symptoms: GSM can cause a range of urinary issues, including increased frequency of urination, urgency, urinary tract infections (UTIs), and incontinence. Estrogen plays a role in maintaining the health of the urinary tract, so its decline can lead to irritation and increased susceptibility to infections.

4. Pelvic Floor Dysfunction: abnormal tone or weakening of pelvic floor muscles exacerbates urinary symptoms and pain, and contributes to conditions like pelvic organ prolapse.

5. Changes in Vaginal pH: Estrogen plays a critical role in maintaining a healthy vaginal environment. With lower estrogen levels, the vaginal pH becomes less acidic, making the area more susceptible to infections such as bacterial vaginosis and yeast infections.

Causes and Risk Factors
GSM is directly related to the reduction in estrogen production during menopause. Estrogen is responsible for maintaining the thickness, elasticity, and moisture of the vaginal and urinary tissues. As levels drop, these tissues undergo changes that lead to GSM.

While GSM is most commonly associated with natural menopause, it can also occur in women who experience early menopause due to surgery or cancer treatments like chemotherapy and radiation. Women who smoke or have never given birth vaginally are also at a higher risk for developing GSM.

Treatment Options:
The good news is that GSM is treatable. While you might think, systemic hormone replacement therapy (HRT) is enough to resolve GSM, that’s not typically the case. More often, even if one is on already on estrogen HRT, or for those who cannot or will not take systemic estrogen, they can still apply a low dose estradiol cream specifically to the vestibule, urethra, and vaginal opening to target the tissue most affected by GSM. Local topical estradiol cream is considered a safe option. In a recent article, “In a large, claims-based analysis, we did not find an increased risk of breast cancer recurrence within 5 years in women with a personal history of breast cancer who were using vaginal estrogen for genitourinary syndrome of menopause”

However, if one is still opposed to using estradiol, other non-hormonal options are available to treat GSM symptoms:

1. Vaginal Moisturizers and Lubricants: For women experiencing mild symptoms, over-the-counter vaginal moisturizers and lubricants can provide relief from dryness and discomfort. These products can be used regularly to help maintain vaginal moisture and make intercourse more comfortable.

2. Pelvic Floor Physical Therapy: Many women with GSM benefit from pelvic floor physical therapy, which can strengthen the muscles of the pelvic floor, improve bladder control, and enhance sexual function. Physical therapists specialized in pelvic health can provide individualized treatments to address specific concerns.

3. Laser Therapy: A newer, non-invasive option for GSM is laser therapy, such as fractional CO2 lasers. This therapy stimulates collagen production in the vaginal tissues, promoting healing and improving symptoms of dryness, pain, and laxity.

4. Lifestyle Modifications: Quitting smoking, maintaining a healthy weight, and staying sexually active can also help reduce symptoms of GSM. Regular sexual activity increases blood flow to the vaginal area, helping to maintain tissue health.

Our Role as Pelvic Floor Therapist:
Despite affecting up to half of postmenopausal women, GSM remains underdiagnosed and undertreated. Many women may feel uncomfortable discussing these symptoms with their healthcare providers, or they may assume that these changes are a natural part of aging that must be endured. That is where pelvic floor specialists have a unique opportunity to educate these women. We have the luxury of one-on-one time and we are one of the only specialists that fully assess the vulvar tissue, specifically the vestibule and urethral opening where GSM is most identifiable. Understanding the research on estradiol treatment as well as other non-hormonal options can greatly improve our patients' quality of life.

Join Tara Sullivan in her upcoming course to learn more about Sexual Medicine in Pelvic Rehab on October 19-20. Lecture topics include hymen myths, squirting, G-spot, prostate gland, sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm, and function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy; as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. 

 Resource:

•  Agrawal P, Singh SM, Able C, Dumas K, Kohn J, Kohn TP, Clifton M. Safety of Vaginal Estrogen Therapy for Genitourinary Syndrome of Menopause in Women With a History of Breast Cancer. Obstet Gynecol. 2023 Sep 1;142(3):660-668. doi: 10.1097/AOG.0000000000005294. Epub 2023 Aug 3. PMID: 37535961. https://pubmed.ncbi.nlm.nih.gov/37535961/

AUTHOR BIO:
Tara Sullivan, PT, DPT, PRPC, WCS, IF

Dr. Tara Sullivan, PT, PRPC, WCS, IF (she/her) started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage, anatomy, and physiology. During that time, she attended college at Oregon State University earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Masters of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD) treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC) deeming her an expert in pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company Mind to Body Healing (M2B) to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.

Faculty member Christine Stewart, PT, CMPT began her career specializing in orthopedics and manual therapy and became interested in women’s health after the birth of her second child.  Christine joined Olathe Health in 2010 to further focus on women’s health and obtain her CMPT from the North American Institute of Manual Therapy. She also went through Diane Lee's integrated systems model in 2018. Her course, Menopause Transitions and Pelvic Rehab is designed for the clinician that wants to understand the multitude of changes that are experienced in the menopause transition and how they affect the aging process. 

Menopause. The M-word, the second puberty, is the final frontier of a hormonal roller coaster when there are twelve consecutive months with no menstruation. A time of celebration, right? No more cramps, hygiene products, menstrual cups, or moodiness – FREEDOM! Not so fast my fellow clinician!

The body goes through some serious, hormonal loop-the-loops leading up to the cessation of ovulation. Perimenopause is the stretch leading up to the final cycle and this stretch can feel like yoga on steroids. It can last TEN years, not including symptoms experienced after the transition takes place. Changes in cycle length, flow, anovulation, and yes, even ovulating twice are all stages of perimenopause. (Hale et al., 2009). These changes translate into symptoms: sleeplessness, brain fog, anxiety, palpitations, fatigue, painful intercourse, and joint stiffness are just a few things that can be experienced during this time (Lewis, 2021).

This transition can begin for patients during their mid-thirties, more commonly it begins during their forties, but eventually, all people that ovulate will experience it. For some, perimenopause can be much more challenging than after menopause. The perimenopause hormone guessing game begins. Some months, progesterone makes an appearance. The next month, mostly estrogen, and some months - neither are around very much at all. If there is an abrupt change in ovulation, such as with a complete hysterectomy, the symptoms will most likely be intensified due to the abrupt loss of hormones. (Gunter, 2020). Dealing with the changes of menopause can be challenging in a variety of ways (like a two-year-old wailing for a candy bar in the checkout line), but many things can help ease this transition.

With fluctuating hormones also comes changes to many systems in the body. Estrogen receptors are everywhere, and when hormone levels are changing, so does the body’s internal workings. Glucose metabolism, bone physiology, brain, and urogenital function are just some of the systems affected (Shifren et al., 2014). Perimenopause is not just a time of altered periods. It is also a critical time in a person’s health where an increased incidence of heart disease, diabetes, and bone loss can begin (Lewis 2021).

Preparing for menopause should be on our radar for patients in their twenties, thirties, and early forties before the process starts. Establishing healthy habits earlier instead of later can help for a more successful transition, however, it is never too late! Knowing the signs and symptoms of this phase can help us guide patients and ourselves to a better understanding of what is happening with the body in this adaptation. We can make recommendations on lifestyle, exercise, and meditation, as well as refer them to other knowledgeable providers when needed.

I have had countless patients sent to me for urinary frequency, incontinence, or painful intercourse who are in this transition, but no one has talked to them about what is happening to their bodies. You may be thinking to yourself, these patients have doctors. Why aren’t they getting the information from their physician? After all, these providers have had years of training. The reality is sometimes doctors do not receive the necessary education to treat menopausal patients. 

In a survey of postgraduate trainees in internal medicine, family medicine, and obstetrics/gynecology, 90% felt unprepared to manage women experiencing menopause (Reid, 2021). Insert jaw drop here. As pelvic health providers, we can help to fill this knowledge gap and be a conduit to explaining the process. We can empower patients with education, treatments, and recommendations to flourish in this critical phase of life.

The menopause transition can be a time of great uncertainty. Not only are patients’ lives transforming as their children grow and their parents age, but their bodies are changing as well. We can ease their burden in this period of adaptation. By calming their fears through education, we can assure them that indeed, they are not losing their minds.

Knowledge is power, and I am all in when it comes to empowering patients. They can learn that menopause is a phase and does not define who they are as a person. It is possible to survive and come out on the other side still thriving, while learning how to cope during the process. There is hope! 

Menopause Transitions and Pelvic Rehab is an excellent opportunity to understand the physiological consequences to the body as hormones decline, in order to assist our patients in lifestyle habits for successful aging. Lecture topics include cardiovascular changes, metabolic syndrome, bone loss and sarcopenia, neurological changes (headache, brain fog, sleeplessness), Alzheimer’s risk, urogenital changes, as well as symptoms and treatment options. These include hormone replacement, non-hormonal options, dietary choices, and exercise considerations. 

A question that often comes up in conversation around menopause is that of pelvic health – the effects on bladder, bowel or sexual health…what works, what’s safe, what’s not? Is hormone therapy better, worse or the same in terms of efficacy when compared to pelvic rehab? Do we have a role here?

An awareness of pelvic health issues that arise at menopause was explored in Oskay’s 2005 paper ‘A study on urogenital complaints of postmenopausal women aged 50 and over’ stating ‘…Urinary incontinence and sexual problems, particularly decline in sexual desire, are widespread among postmenopausal women. Frequent urinary tract infections, obesity, chronic constipation and other chronic illnesses seem to be the predictors of UI.’

Moller’s 2006 paper explored the link between LUTS (Lower Urinary Tract Symptoms) and sexual activity at midlife: the paper discussed how lower urinary tract symptoms (LUTS) have a profound impact on women’s physical, social, and sexual well being, and confirmed that LUTS are likely to affect sexual activity. However, they also found that conversely, sexual activity may affect the occurrence of LUTS – in their study a questionnaire was sent to 4,000 unselected women aged 40–60 years, and they found that compared to women having sexual relationship, a statistically significant 3 to 6 fold higher prevalence of LUTS was observed in women with no sexual relationship. They also found that women who ceased sexual relationship an increase in the de novo occurrence of most LUTS was observed, concluding that ‘…sexual inactivity may lead to LUTS and vice versa’.

So, who advises women going through menopause about issues such as sexual ergonomics, the use of lubricants or moisturisers, or provide a discussion about the benefits of local topical estrogen? As well as providing a skillset that includes orthopaedic assessment to rule out any musculo-skeletal influences that could be a driver for sexual dysfunction? That would be the pelvic rehab specialist clinician! Tosun et al asked the question ‘Do stages of menopause affect the outcomes of pelvic floor muscle training?’ and the answer in this and other papers was yes; with the research comparing pelvic rehab vs hormone therapy vs a combination approach of pelvic rehab and topical estrogen providing the best outcomes. Nygaard’s paper looked at the ‘Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence’ and concluded that : ‘…(both pre and postmenopausal women) benefit from motor learning strategies and adopt functional training to improve their urinary symptoms in similar ways, irrespective of hormonal status or HRT and BMI category’.

We must also factor in some of the other health concerns that pelvic health can impact at midlife for women – Brown et al asked the question ‘Urinary incontinence: does it increase risk for falls and fractures?’ They answered their question by concluding that ‘‘… urge incontinence was associated independently with an increased risk of falls and non-spine, nontraumatic fractures in older women. Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures. Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture.’

If you are interested in learning more about pelvic health, sexual function and bone health at Menopause, consider attending Menopause Rehabilitation and Symptom Management.

Sexual activity and lower urinary tract symptoms’ Møller LA1, Lose G. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):18-21. Epub 2005 Jul 29.
A study on urogenital complaints of postmenopausal women aged 50 and over. Oskay UY1, Beji NK, Yalcin O. Acta Obstet Gynecol Scand. 2005 Jan;84(1):72-8.
Do stages of menopause affect the outcomes of pelvic floor muscle training? Tosun ÖÇ1, Mutlu EK, Tosun G, Ergenoğlu AM, Yeniel AÖ, Malkoç M, Aşkar N, İtil İM. Menopause. 2015 Feb;22(2):175-84. doi: 10.1097/GME.0000000000000278.
‘Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence.’ Nygaard CC1, Betschart C, Hafez AA, Lewis E, Chasiotis I, Doumouchtsis SK. Int Urogynecol J. 2013 Dec;24(12):2071-6. doi: 10.1007/s00192-013-2179-7. Epub 2013 Jul 17

The new year is here and with it, lots of motivational posting about exercise and weight loss…but how is this desire for ‘new year, new you’ affecting peri-menopausal women with urinary dysfunction? It has been established that the lower urinary tract is sensitive to the effects of estrogen, sharing a common embryological origin with the female genital tract, the urogenital sinus. Urge urinary incontinence is more prevalent after the menopause, and the peak prevalence of stress incontinence occurs around the time of the menopause (Quinn et al 2009). Zhu et al looked at the risk factors for urinary incontinence in women and found that some of the main contributors include peri/post-menopausal status, constipation and central obesity (women's waist circumference, >/=80 cm) along with vaginal delivery/multiparity.

Could weight loss directly impact urinary incontinence in menopausal women? In a word – yes. ‘Weight reduction is an effective treatment for overweight and obese women with UI. Weight loss of 5% to 10% has an efficacy similar to that of other nonsurgical treatments and should be considered a first line therapy for incontinence’ (Subak et al 2005) But do these benefits last? Again – yes! ‘Weight loss intervention reduced the frequency of stress incontinence episodes through 12 months and improved patient satisfaction with changes in incontinence through 18 months. Improving weight loss maintenance may provide longer term benefits for urinary incontinence.’ (Wing et al 2010)

The other major health issues facing women at midlife include an increased risk for cardiovascular disease, Type 2 Diabetes and Bone Health problems – all of which are responsive to lifestyle interventions, particularly exercise and stress management. In their paper looking at lifestyle weight loss interventions, Franz et al found that ‘…a weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals’. 5% weight loss is the same amount of weight loss necessary to provide significant benefits for urinary incontinence at midlife.

Successful weight management depends on nutritional intake, exercise and psychosocial considerations such as stress management, but for the menopausal woman, hormonal balance can also have an effect on not only bladder and bowel dysfunction but changing metabolic rates, thyroid issues and altered weight distribution patterns. As pelvic rehab therapists, we are all aware that pelvic health issues can be a barrier to exercise participation but sensitive awareness of the other particular challenges facing midlife women can make the difference in developing a beneficial therapeutic alliance and a journey back to optimal health. If you would like to explore the topics surrounding optimal health at menopause, why not join me in California in February?

Climacteric. 2009 Apr;12(2):106-13. ‘The effects of hormones on urinary incontinence in postmenopausal women.’ Quinn SD, Domoney C. Menopause. 2009 Jul-Aug;16(4):831-6. The epidemiological study of women with urinary incontinence and risk factors for stress urinary incontinence in China’ Zhu L, Lang J, Liu C, Han S, Huang J, Li X. J Urol. 2005 Jul;174(1):190-5. Weight loss: a novel and effective treatment for urinary incontinence’ Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. J Urol. 2010 Sep;184(3):1005-10. Effect of weight loss on urinary incontinence in overweight and obese women: results at 12 and 18 months Wing RR, West DS, Grady D, Creasman JM, Richter HE, Myers D, Burgio KL, Franklin F, Gorin AA, Vittinghoff E, Macer J, Kusek JW, Subak LL; Program to Reduce Incontinence by Diet and Exercise Group. J Acad Nutr Diet. 2015 Sep;115(9):1447-63. doi: 10.1016/j.jand.2015.02.031. Epub 2015 Apr 29. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lean, M, & Lara, J & O Hill, J (2007) Strategies for preventing obesity. In: Sattar, N & Lean, M (eds.) ABC of Obesity. Oxford, Blackwell Publishing.

Perimenopausal pelvic health issues are, for many of us, some of the most common issues that we see in the women that we work with. Urinary incontinence is one of the most important issues for peri- and postmenopausal women. In Melville’s study¹ of U.S. women, half of the participants between the ages of 50 and 90 experienced urine leakage every month. Zhu’s 2008 study² looked at the risk factors for SUI - Multiple vaginal deliveries, Age/postmenopausal status, Chronic pelvic pain, Obesity, lack of exercise, constipation, and hypertension. But what is not often (enough) looked at in the research, is the link between urinary dysfunction and sexual dysfunction – usually because questions aren’t asked or assumptions are made. In Mestre et al’s 2015 paper³, they write ‘…Integrating sexual health in clinical practice is important. In women with pelvic floor disorders, the evaluation of the anatomical defects, lower urinary tract function and the anorectal function often receives more attention than sexual function.’

But are they linked?

In Moller’s exploration of this topic, they report that lower urinary tract symptoms (LUTS) have a profound impact on women’s physical, social, and sexual wellbeing. Unsurprisingly (to pelvic rehab specialists at least!), they found that the LUTS are likely to affect sexual activity. Conversely, sexual activity may affect the occurrence of LUTS. The aims of the Moller study were to elucidate to which extent LUTS affect sexual function and to which extent sexual function affect LUTS in an unselected population of middle-aged women in 1 year. A questionnaire was sent to 4,000 unselected women aged 40–60 years. Compared to women having sexual relationship, a statistically significant 3 to 6 fold higher prevalence of LUTS was observed in women with no sexual relationship. In women who ceased sexual relationship an increase in the de novo occurrence of most LUTS was observed. In women who resumed sexual relationship a decrease in LUTS was observed. In women whose sexual activity was unchanged no change in the occurrence of LUTS. So they rightfully concluded ‘…sexual inactivity may lead to LUTS and vice versa.’

In my Menopause course, we will explore the range of perimenopausal pelvic health issues that many women face and their inter-related nature – not just with each other but also how orthopaedic, endocrine and gastro-intestinal health issues influence pelvic health and wellness. Interested in learning more? Come and join the conversation in California in February 2018!

1. Melville JL, et al. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005;165(5):537-42 - See more at: http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=698029#sthash.cm8A90tS.dpuf
2. Zhu L1, Lang J, Wang H, Han S, Huang J. Menopause. 2008 May-Jun;15(3):566-9. The prevalence of and potential risk factors for female urinary incontinence in Beijing, China
3. Mestre M, Lleberia J, Pubill J, Espuña-Pons M Actas Urol Esp. 2015 Apr;39(3):175-82. Epub 2014 Aug 28. Questionnaires in the assessment of sexual function in women with urinary incontinence and pelvic organ prolapse.

One of my greatest nemeses when I was racing at 30 years of age was a woman in her 50’s. Although I hated losing to her, I was always inspired by her speed at her age. She motivated me to continue training hard, realizing my fastest days could be yet to come. As I now race in the “master’s” category in my 40’s, I still find myself crossing the line behind an older competitor occasionally. Research shows I should take heart and keep in step with females who continue to move their bodies beyond menopause.

Mazurek et al., (2017) studied how organized physical activity among post-menopausal women could reduce cardiovascular risk. The study included 35 sedentary women aged 64.7 ± 7.7 years who had no serious health issues. They all participated in the Active Leisure Time Programme (ALTP) 3 times per day for 40–75 minute sessions for 2 weeks, including 39 physical activities. Exercise intensity stayed within 40–60% of maximal HR, and ratings of perceived exertion (RPE) on the Borg scale stayed between 8 and 15 points. This exercise training was followed by 3 months of the Prevent Falls in the Elderly Programme (PFEP), which is a general fitness exercise program to prevent falls in the elderly. Health status was measured at baseline, 2 weeks into the program, and after 3 months. The results showed significant reductions in central obesity, which increased the exercise and aerobic capacity of the subjects and improved lipid profiles. A significant reduction also occurred in the absolute 10-year risk of death from cardiac complications. The authors concluded these exercise programs could be effective in preventing primary and secondary cardiovascular disease in the >55 years old female population.

Nyberg et al., (2016) took a physiological look at exercise training on the vascular function of pre- and postmenopausal women, studying the prostanoid system. Prostanoids are vasoconstrictors, and prostacyclins are vasodilators. The loss of estrogen in menopause affects the ability of the vasodilators to function properly or even be produced, thus contributing to vascular decline. The authors checked the vasodilator response to an intra-arterial fusion of a prostacyclin analog epoprostenol as well as acetylocholine in 20 premenopausal and 16 early postmenopausal women before and after a 12-week exercise program. Pre-exercise, the postmenopausal women had a reduced vasodilator response. The women also received infusion of ketorolac (an inhibitor of cyclooxygenase) along with acetylcholine, creating a vasoconstriction effect, and the vascular response was reduced in both groups. The infusions and analyses were performed again after 12 weeks of exercise training, and the exercise training increased the vasodilator response to epoprostenol and acetylcholine in the postmenopausal group. The reduced vasodilator response to epoprostenol prior to exercise in early postmenopausal women suggests hormonal changes affect the capacity of prostacyclin signaling; however, the prostanoid balance for pre and postmenopausal women was unchanged. Ultimately, the study showed exercise training can still have a positive effect on the vascularity of newly postmenopausal women.

There are randomized controlled clinical trials and scientific evidence supporting the importance to keep moving as women (and men) age. Menopause should not be a self-proclaimed pause from activity in life. Not everyone has to become a competitive athlete to preserve cardiac and vascular integrity as we age, but we need to engage in some physical activity to keep our systems running for years to come.

Those interested in learning more about menopause rehabilitation considerations should consider attending Menopause Rehabilitation and Symptom Management.

Mazurek, K., Żmijewski, P., Kozdroń, E., Fojt, A., Czajkowska, A., Szczypiorski, P., Tomasz Mazurek, T. (2017). Cardiovascular Risk Reduction in Sedentary Postmenopausal Women During Organised Physical Activity. Kardiologia Polska. 75, 5: 476–485. http://doi:10.5603/KP.a2017.0035
Nyberg, M., Egelund, J., Mandrup, C., Nielsen, M., Mogensen, A., Stallknecht, B., Bangsbo, J., Hellsten, Y. (2016). Early Postmenopausal Phase Is Associated With Reduced Prostacyclin-Induced Vasodilation That Is Reversed by Exercise Training: The Copenhagen Women Study. Hypertension. 68:1011-1020. https://doi.org/10.1161/HYPERTENSIONAHA.116.07866

What's the evidence, and what's the answer?

In getting ready to teach my Menopause course in Minneapolis next month, I always like to do a review of the evidence, to see what’s new, or what’s changed. What has changed over the past few years – more and more evidence to support the role of skilled rehab providers, using evidence based assessment techniques to gauge the grade of pelvic organ prolapse and assess the risk of levator avulsion. What hasn’t changed enough – the level of awareness of the benefits of pelvic rehab in managing, or in some cases even reversing, the effects and symptoms of prolapse.

Dr Peter Dietz, from the University of Sydney, writes ‘…although clinical anecdote suggests some physiotherapists recognize other characteristics suggesting muscle dysfunction (e.g. holes, gaps, ridges, scarring) or pelvic floor dysfunction (e.g. width between medial edges of pelvic floor muscle) with palpation it is difficult to find any literature describing the techniques needed to do this or their accuracy or repeatability. Mantle (in 2004) noted that with training and experience a physiotherapist might be able to discern muscle integrity, scarring, and the width between the medial borders of the pelvic floor muscles, with palpation. It is not clear to what extent physiotherapists are able to do this reliably or how such characteristics are to be recorded.’

Dr Dietz describes a palpation technique to assess the integrity of the pubovisceral muscle insertion, by checking the gap between the urethra centrally and the pubovisceral muscle laterally. On levator contraction this gap should be little wider than your index finger, otherwise an avulsion injury is very likely.

There is another aspect of levator assessment that can yield important information on clinical examination. The size of the levator hiatus can be estimated by determining the sum of the genital hiatus (gh) and perineal body (pb) in the context of the ICS POP-Q examination. Gh + pb, ie., the distance between the external urethral meatus and the centre of the anus, when measured on maximal Valsalva with a simple ruler, is highly predictive of symptoms and signs of prolapse, and it is very strongly correlated with hiatal area on Valsalva (Khunda et al., 2011).

Using this research, in the lab sessions of the Menopause course, we will review these palpation and measurement skills to give therapists the skills they need to confidently assess risk of levator avulsion and its impact on pelvic organ prolapse, and to use this information to devise a functionally appropriate rehab program.

Come and join the conversation in my course, Menopause Rehabilitation and Symptom Management!

Khunda A1, Shek KL, Dietz HP., Am J Obstet Gynecol. 2012 Mar;206(3):246.e1-4. doi: 10.1016/j.ajog.2011.10.876. Epub 2011 Nov 7. Can ballooning of the levator hiatus be determined clinically?

With menopause and the hormonal shifts that take place, some women suffer more than others with symptoms such as hot flashes. If you have ever been near someone during a hot flash, you know that this curious condition is more than feeling a little hot under the collar. During a hot flash, women will suddenly disrobe, wake from a deep sleep covered in sweat (so much so that they have to change the sheets!), or otherwise appear distressed and oftentimes suffer interference in whatever activity in which they were engaging. As we reported in an earlier post, women on average may have hot flashes for 5 years after the date of her last period. Some women (up to 1/3 in the referenced study) will report hot flashes for 10 or more years after menopause.

Hot flashes and night sweats also significantly disrupt sleep, according to research by Baker and colleagues. Menopausal women with insomnia may also have higher levels of psychologic, somatic, vasomotor symptoms, and score lower on the Beck Depression Inventory, and sleep efficiency and duration scores. Poor sleep can be associated with morbidity such as hypertension, stroke, diabetes and depression, so interrupted sleep is more than an inconvenience, but potentially a serious health issue.

A more recent study linked anxiety as a potential risk factor for menopausal hot flashes. In 233 women who are premenopausal at baseline and who were followed for at least a year after their final menstrual cycle, anxiety symptoms, hormone levels, hot flashes and other psychosocial variables were assessed. During the 14 year follow-up 72% of the women reported having moderate to severe hot flashes, and the researchers correlated somatic anxiety as a potential predictive association with anxiety. Somatic anxiety refers to the physical symptoms of anxiety, such as stomach ache, increased heart rate, sweating, muscle aches.

In order to help a woman support her wellness during menopausal transitions, being able to address somatic anxiety and conditions like hot flashes is imperative. Teaching skills such as breathing, relaxation training, meditation, or mindfulness may positively impact the anxiety, and therefore have the potential to reduce hot flashes and other adverse symptoms. Herman & Wallace's Menopause Rehabilitation and Symptom Management course is an excellent opportunity to learn some of these valuable skills.

Baker, F. C., Willoughby, A. R., Sassoon, S. A., Colrain, I. M., & de Zambotti, M. (2015). Insomnia in women approaching menopause: beyond perception. Psychoneuroendocrinology, 60, 96-104.
Freeman, E. W., & Sammel, M. D. (2016). Anxiety as a risk factor for menopausal hot flashes: evidence from the Penn Ovarian Aging cohort. Menopause, 23(9), 942-949.
Freeman, E. W., Sammel, M. D., & Sanders, R. J. (2014). Risk of long term hot flashes after natural menopause: Evidence from the Penn Ovarian Aging Cohort. Menopause (New York, NY), 21(9), 924.

Vaginal wall thinning associated with menopausal changes can cause vaginal burning and pain, limitations in sexual function, and vaginal redness or even changes in discharge. Because these symptoms can mimic many other conditions such as pelvic floor muscle dysfunction or an infection, it is necessary for the pelvic rehabilitation therapist to be alert to identifying vaginal atrophy as an issue to rule out so that patients can access appropriate medical care when needed.

Atrophic vaginitis (AV) is a condition of the vaginal walls associated with tissue thinning, discomfort, and inflammation. The tissue changes often extend into the vulvar area as well. Atrophic vaginitis may also be called vaginal atrophy, vulvovaginal atrophy, urogenital atrophy, or genitourinary syndrome of menopause. Although we tend to associate menopause with women who are in their 40’s or 50’s, any woman who has stopped having her menstrual cycles or who has had a significant reduction in her cycles may be at risk for vaginal atrophy. Any woman who has had a hysterectomy may also be at risk of this thinning of the vaginal walls. Common symptoms of vaginal wall thinning include vaginal dryness, tissue irritation, redness, itching, and a “burning” pain. Interruption in sleep, limitations in activities of daily living, and changes in mood and temperament have also been reported.

One common pharmacological intervention for vaginal and vulvar atrophy is the topical application of hormone creams such as estrogen. A recent study examined the effects of low dose estrogen therapy on bacteria that populates the vaginal walls.^{Shen et al., 2016} This bacteria may be causal or correlated to vaginal health, and also appears related to estrogen levels. Sixty women diagnosed with atrophic vaginitis were treated with low dose estrogen therapy and followed for four weeks to assess the vaginal microbiotia via mid-vaginal swabs. Following are highlights from the linked study’s findings,

• Prior to treatment, in symptomatic postmenopausal women the Lactobacilli species were less abundant and made up 11.2% of the community, while in asymptomatic women, the communities were more than 50% lactobacilli
• Gardnerella was more abundant than Lactobacillus in women with atrophic vaginitis
• Overall diversity of bacterial communities between healthy women and those with atrophic vaginitis was not significantly different
• In response to treatment with estrogen, women with AV reported improved symptoms and decreased vaginal pH
• Serum estradiol improved on average from approximately 42 pmol/L to 168 pmol/L by week 2, with little change from week 2 to week 4
• Lactobacillus count was negatively correlated with symptoms (i.e., more Lactobacillis = less symptoms) and Gardnerella and Atopobium counts were positively correlated with symptoms
• There were variations noted in how each woman’s vaginal bacterial communities responded to the estrogen therapy in that some women had a dominance of other bacteria after 4 weeks even though their symptoms decreased

In conclusion, the authors stated that “…a Lactobacillus-dominated vaginal community may be considered as one of the signs of AV treatment success…” along with reduced symptoms and increased serum estradiol levels. Prior studies have recognized barriers to treatment that include lack of patient knowledge of vulvar and vaginal atrophy, failure to discuss associated symptoms with physicians, concerns about safety of treatments or poor symptom relief with prescribed interventions.^{Kingsburg et al., 2013} This leaves the pelvic rehabilitation provider in a excellent role of educating women in the signs and symptoms of atrophic vaginitis, observing the tissues for changes, and communicating with referring providers and prescribers if a concern is noted. Furthermore, failure to recognize the potential for vaginal atrophy and treating these tissues with manual therapy or exercise may injure or exacerbate the problem.

Interested in learning more? Keep an eye out for a Menopause Rehabilitation and Symptom Management course with Michelle Lyons!

Changes in the Vagina and Vulva. Retrieved June 27, 2016 from http://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
Kingsberg, S. A., Wysocki, S., Magnus, L., & Krychman, M. L. (2013). Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. The journal of sexual medicine, 10(7), 1790-1799. 
Shen, J., Song, N., Williams, C. J., Brown, C. J., Yan, Z., Xu, C., & Forney, L. J. (2016). Effects of low dose estrogen therapy on the vaginal microbiomes of women with atrophic vaginitis. Scientific reports, 6.
Vaginal Atrophy. Retrieved June 27, 2016 from http://www.mayoclinic.org/diseases-conditions/vaginal-atrophy/home/ovc-20200167