Ever Since I Had My Baby

by Roger Goldberg

  STAY ACTIVE, BUT KNOW WHAT TO AVOID IF SYMPTOMS ARISE

  We’ve discussed how evolution has left the female pelvic floor quite vulnerable to physical forces within the abdomen and pelvis, and the similarity between female pelvic prolapse and hernias in men. So it should come as no surprise to hear that a routine filled with heavy exertion may cause prolapse and incontinence to occur more rapidly. On rare occasion, even one particularly strenuous set of activities—like several days of heavy lifting during a move, or a summer of intense work in the garden—can have a noticeable effect.

  On the other hand, it’s common for women with prolapse and incontinence to get out of shape as they begin to avoid situations that might make their pelvic symptoms feel worse, or leave them feeling more vulnerable to accidents. Among 290 regular exercisers surveyed in one gynecologic practice, 20 percent of those with urinary incontinence reported that they stopped exercising because of this problem. Patients with advanced prolapse often follow a similar pattern. Allowing your physical fitness to decline is the worst possible effect that a pelvic-floor condition can have on your life. Your risk for a number of far more serious problems, such as heart disease, osteoporosis, stress, and even depression, will only increase. More specifically, for women choosing surgery to address their pelvic-floor problem, obesity means a higher risk that the operation will fail to provide a cure over the long run, due to the stress of excess pounds on the pelvic-floor supports. What’s the best advice if you’re already dealing with postreproductive symptoms? Stay active while keeping a few sensible tips in mind.

  Think low-impact. It’s important to appreciate the way physical impact is absorbed by your body and the effect it can have on existing pelvic-floor problems over the long run. Particularly if you’re coping with prolapse, beware of high-impact activities such as martial arts, weight lifting, crunches, horseback riding, and heavy aerobics, if they’re exacerbating your symptoms down below. Focus on exercises that strengthen your midbody, pelvic area, and thighs until you’re evaluated by a physician.

  Yoga. Provides a great low-impact routine, strengthening the thighs, back, and trunk while improving posture.

  Walking, biking, water exercise, swimming. Great workout options that create minimal pelvic stress.

  Abdominal exercise. Certain muscles in the abdominal wall may contribute to the function of your pelvic floor; as a result, abdominal muscle training might play a role in rehabilitating a dysfunctional pelvic floor. For starters, try fifteen sit-ups each morning, and over time, increase to thirty. That simple routine may give you that six-pack abdomen you always wanted while also preventing pelvic-floor problems.

  Bridges are done while lying faceup on a mat or soft surface. They help to strengthen the midbody from the buttocks to the abdominals. With your knees bent, try slowly lifting your body, keeping only your heels and shoulders on the floor. With practice, try increasing your lift time from five seconds to a full minute; to increase the difficulty, more your feet farther away from your hips. Pelvic tilts are another popular low-impact abdominal strengthener during pregnancy and afterward (see chapter 4).

  Say good-bye to heavy hauling. Keep exercising and stay as fit as you can, but if you’re dealing with significant prolapse or incontinence, bid farewell to the joys of lifting heavy boxes, rearranging furniture, or hauling oversize bags of gardening soil, at least until you’re evaluated by the doctor.

  When you need to do heavy work, do it right. If you do find it necessary to lift a heavy object, brace your pelvic floor with a Kegel squeeze, and exhale as you lift. Holding your breath will only increase the pressure on your most important pelvic supports. A few ounces of prevention—by modifying your activities and learning to brace your pelvic floor—may help keep you out of trouble down the road.

  GENERAL MEDICAL AILMENTS

  VASCULAR PROBLEMS, HIGH BLOOD PRESSURE, AND HEART DISEASE

  Swelling of the feet and lower legs during the daytime—in some cases caused by heart conditions, large varicose veins, or certain medications—can lead to an abnormally high output of urine at night. This nighttime flooding (diuresis, in medical terms) is a result of fluid draining from the swollen lower extremities back into the bloodstream and eventually through the kidneys.

  Some medications for high blood pressure may relax the urethra and bladder neck, sometimes enough to make incontinence worse. If you’re on a medication for blood pressure or a heart condition, or a diuretic (water pill), ask your doctor whether it might be contributing.

  RESPIRATORY CONDITIONS

  Control asthma, and consider a flu shot. Many women can testify that a bad bout of bronchitis can push mild incontinence symptoms into a much bigger problem. Over time, a chronic cough may increase the wear and tear on your pelvic-floor supports, setting the stage for worsening prolapse, incontinence, and overall problems related to the pelvic floor. Chronic obstructive pulmonary disease (COPD), a lung condition often caused by smoking, is associated with urinary incontinence rates of up to 66 percent, and also more nighttime voiding.

  DIABETES

  Long-standing diabetes can cause a number of urinary problems, including bladder weakness, urinary retention, and overflow incontinence. When diabetes is poorly controlled, excess glucose may be excreted through the kidneys, causing an elevated urine output. Careful glucose control will benefit a number of bodily organs, including your bladder.

  NEUROLOGIC PROBLEMS

  Stroke, multiple sclerosis, Parkinson’s disease, and other neurological problems can result in overactive-bladder symptoms, urge incontinence, urinary retention, and overflow incontinence. Although these diseases are chronic, they are often manageable in many ways, and extra attention to pelvic-floor symptoms can make a big difference in quality of life.

  OBESITY

  Being overweight puts you at higher risk for incontinence and prolapse by stressing the pelvic-floor supports. As an extreme example, one interesting 1992 study from the Medical College of Virginia evaluated urinary symptoms among obese women, before and then after surgically induced weight loss (stomach stapling). The study showed significant improvement in urinary symptoms after weight loss. Of twelve women who complained of incontinence before surgery, all but three resolved afterward. In Norway, the EPICONT study involving nearly twenty-eight thousand women revealed obesity as a clear risk factor for urinary incontinence. In other words, losing weight may sometimes prove to be the only therapy you need for your postreproductive problem.

  WHAT YOU WEAR

  Yes, even your wardrobe might affect the way your postreproductive body feels. Synthetic materials, for instance, can irritate the urethra and vagina and trigger pelvic symptoms. Wear cotton instead of nylon undergarments. If urinary or vaginal infections are a problem, avoid wearing tight clothing. Girdles or corsets, which squeeze the abdomen tightly, might actually strain the pelvic supports if worn regularly. If you’re coping with pelvic-floor symptoms or recovering from surgery, these garments are probably not your best choice.

  Tip #4: Quit Smoking

  You know all about the effects of smoking on your heart, lungs, and blood vessels, and you’ve heard everything there is to hear about the links between cancer, strokes, and cigarettes. Why mention smoking in a book on postreproductive problems involving your pelvic area? Smoking also spells bad news for women with prolapse, incontinence, and other bladder symptoms. One study found that if you currently smoke or did so in the past, your risk of urinary incontinence is up to twice that of a nonsmoker, and your risk of pelvic prolapse may also be higher. The Norwegian EPICONT study also found higher rates of severe incontinence among smokers.

  One major reason is the chronic smoker’s cough. Whether it arises from asthma, bronchitis, emphysema, or the host of other smoking-related problems, a smoker’s cough delivers a constant stress test to the pelvic floor and vaginal supports. Over time, this not only creates a higher risk for stress incontinence and prolapse but also decreases the chance of a surgical repair holding up over t
he long run.

  Smoking can also mean trouble for an overactive bladder or urge incontinence. That’s because nicotine can trigger contractions of the smooth muscle within the bladder wall, and it can also irritate the bladder lining. One British study of more than three thousand women confirmed that cigarette smoking does significantly increase the risk of an overactive bladder. A study from Virginia found that current and former smokers are over twice as likely to report stress incontinence as compared with nonsmokers. There must be quite a few rest-rooms in Marlboro Country for all them wranglers and cowgirls.

  If you’re a smoker who has thought about quitting, consider your postreproductive symptoms yet another good reason to do so. Cutting the habit is one great way you can help preserve the health of both your upper and lower body over the years, and perhaps even prevent a trip to the operating room.

  Tip #5: Manage Menopause Masterfully

  By now you’ve seen volumes of medical hype and endless demographic blurbs written on “the change.” Behind all of the hype is an undeniable fact: the largest group of women in human history will pass through menopause over the next few years. Since many of these women will live as many years without functioning ovaries as they did with them, the physiological changes associated with menopause are taking on ever-increasing significance in women’s health. You’re probably well aware that the hormonal changes accompanying the end of menstruation affect your body in ways both big and small, ranging from simple hot flashes to an elevated risk for heart disease and osteoporosis. Less commonly known is that the same drop in estrogen can play a major role in bringing out postreproductive symptoms for the first time, or making existing problems feel worse.

  Vaginal symptoms. Urogenital atrophy is the most significant consequence of low estrogen levels when it comes to your genital area and urinary tract. During the decades after menopause, some degree of vaginal atrophy is nearly universal. Fortunately, not everyone will be bothered by it, but many are. As previously mentioned, a lack of estrogen can lead to vaginal dryness, causing irritation and even infections. For some women, these are the very first signs of reaching menopause. For others, bothersome vaginal changes don’t arise until years or even decades later.

  Sexually. Vaginal atrophy is a common reason for painful sex. The earliest change is usually vaginal dryness, causing friction during intercourse; later, the vagina may actually become narrower.

  Urinary symptoms. Stress incontinence and/or urge incontinence might emerge, along with weakening of the tissues around the vagina, bladder, and urethra. An estrogen-deprived bladder lining may cause urinary frequency and urges to void throughout the daytime and night. Urogenital atrophy from low estrogen levels can increase your risk for bladder irritation, overactive-bladder symptoms, and even infections. If you noticed one or more of these problems after menopause, local estrogen therapy may provide an effective preventive strategy. In the section ahead, you’ll learn about estrogen creams, vaginal rings, and tablets.

  “IS INCONTINENCE ASSOCIATED WITH MENOPAUSE?”

  That was the title of a recent Australian study involving nearly 1,900 women. It concluded that although incontinence is highly prevalent among women in midlife, the end of ovarian function might not be the key biological risk factor. More than the hormonal change, other factors—such as obstetrical history, body weight, and prior gynecologic surgery—may simply manifest themselves as problems at this time in midlife.

  ESTROGEN AND OTHER HORMONES: THEIR IMPACT ON PELVIC SYMPTOMS

  Estrogen is a vital ingredient for your pelvic area. The urethra, bladder, vagina, and pelvic floor are all incredibly rich with receptors (sites on the cells where hormones attach) for this most famous female hormone. When estrogen is in abundance, the skin, connective tissues, and blood vessels throughout these areas are well fed, well lubricated, thick, and strong. When estrogen is in short supply, after menopause or surgical removal of the ovaries, the lining of the vagina and bladder can become thin, dry, weak, and irritated—in other words, atrophic. Good vaginal bacteria (lactobacilli) may also become less abundant, making some women prone to infection with bad bacterial types or yeast. Urogenital atrophy is a remarkably common cause of vaginal, bladder, and sexual symptoms among postreproductive women.

  When estrogen is replaced, all of these areas of your lower body respond with improved blood flow, thickness, and strength. Estrogen replacement can improve the condition of your pelvic-floor supports and relieve some of the symptoms associated with atrophy in the vagina, urethra, and bladder. But which types will actually work best, and what regimen is healthiest for you?

  A HORMONE-RICH DIET

  Plant Estrogens

  Natural estrogens can be found in more than three hundred plant products and ordinary foods, referred to as isoflavones or phytoestrogens (phyto means plant). They’ve attracted great interest in the past several years, largely over the hope that they might provide a natural way to relieve hot flashes and menopausal symptoms, prevent heart disease and bone loss, and even reduce the risk of breast cancer by providing a more balanced supply of weak estrogen types compared to hormone pills. Much of this optimism arose from the observation that Asian women, who consume at least five times more certain phytoestrogens than Western women, seem to have a lower risk of all these problems. Most of the potential benefits have yet to be scientifically proven. Nevertheless, phytoestrogens can’t hurt you, and hormone-rich foods can be found in some unexpected places.

  Soy. Isoflavones from soy are one of the richest sources of dietary estrogen. Try soy milk (Silk) on cereal. Soybean products (such as roasted soy nuts, soy flour, or boiled soy beans) can deliver high isoflavone content; be aware, however, that soy oil and soy sauce will not. Imitation soy meat (Boca burgers, Soy Dogs) and snack bars are abundant in grocery aisles and do contain isoflavones but are often disappointing to the tastebuds. Tofu is made from soy milk and comes in several forms, ranging from soft to very firm, suitable for cooking, roasting, and frying. Tempeh is fermented soybean, rich in isoflavones and useful as a meat substitute.

  Certain yams. The Mexican wild yam is a highly estrogenic food. Be sure not to confuse it with regular yams or sweet potatoes, neither of which contains significant phytoestrogens.

  Flaxseed. A seed with high estrogen content that can be added into baked goods.

  Kidney and lima beans, chickpeas, seaweed, lentils. Common isoflavone sources.

  Chinese cactus.

  How effectively these plant estrogen sources might ease a specific postreproductive problem—for instance, improving vaginal lubrication, soothing an overactive bladder, or enhancing sexual function—remains uncertain. A small 1990 study of postmenopausal women showed that six weeks of a high soy and flaxseed diet caused increased vaginal lubrication that lasted for two weeks after resuming a regular diet. Currently, the National Institutes of Health is sponsoring research to evaluate the true effects of these substances on a broad range of menopausal symptoms. Even before all the questions have been answered, adding these foods to your diet in moderation may be worth exploring. Try a soy-rich diet for three to six months and see if you notice a change.

  Nina Shandler’s book Estrogen the Natural Way contains hundreds of estrogen-rich recipes from pancakes to soup, and a good discussion of their potential benefits to your heart, bones, and overall health.

  What About Herbal Estrogen?

  Several herbs and supplements may have effects similar to estrogen. But again, don’t assume that they are understood in great detail or that we know their long-term risks. One basic problem of herbal products is that they aren’t held to the same scientific scrutiny as mainstream pharmaceuticals. Their strength can vary widely, and their effects may (just like regular medicines) vary substantially between individuals.

  Dong quai. This well-known herb contains phytoestrols, a weak estrogen source that may (at least in theory) promote hormone production in your body. It has been claimed to help counteract vaginal atrophy, but according to my searc
h of the medical literature, no such evidence yet exists. May be taken as tablets or in the form of a tincture.

  Soy protein. A phytoestrogen source, just like dietary soy.

  Wild-yam extract. Another natural phytoestrogen supplement, in dried extract form.

  Red clover. An herb with significant estrogen content in the form of isoflavones—enough that in the 1940s, Australian sheep grazing on red clover were found to be infertile. They were, in essence, consuming a natural oral contraceptive, with estrogens not unlike those in a regular birth-control pill. Among humans, it’s taken as a pill, capsule, or tea containing the red-cloverleaf extract.

  Black cohosh. A centuries-old wildflower used by Native Americans, touted as a remedy for vaginal dryness and menstrual and menopausal symptoms. Europeans have advocated black cohosh as an estrogen alternative (marketed as Remifemin) for menopause symptoms and hot flashes, and sales in the United States have become substantial. Just like the other herbs on this list, the verdict is still out regarding safety and efficacy.