Bridge Spring 2022

Women's

Christin's storyincontinence isn't just a senior's problem

Anna Lennieflying solo in the NT

Amanda's* storyI always went 'just in case'

Pelvic floor muscle health across a woman's lifespan

BOWEL CONTROL

National

The Foundation, established in 1989, is

Published by the Continence Foundation of Australia

Writer and Editor Nicola Reid Designer Rosa Piciocco ISSN 1836-8107. Online version ISSN 1836-8115.

Bridge is published quarterly by the Continence Foundation of Australia. It is supported by the Australian Department of Health under the National Continence Program.

The information in Bridge is for general guidance only and does not replace the expert and individual advice of a doctor, continence nurse or continence physiotherapist. Bridge cannot be reprinted, copied or distributed unless permission is obtained from the Continence Foundation of Australia.

Advertising The Continence Foundation of Australia appreciates the support of advertisers in publishing Bridge. Advertising conforms to the standards required by the Continence Foundation of Australia, but endorsement is in no way implied by the publishing of said material.

References For a list of references for any articles appearing in Bridge, please email bridge@continence.org.au

Memberships Become an individual, student or professional member of the Continence Foundation of Australia and receive many benefits including discounted registration to the annual National Conference on Incontinence, free publications and timely information about events and education courses.

Email membership@continence.org.au or Phone 03 8692 8400

The Continence Foundation of Australia greatly values the stories people share of living with or caring for someone with incontinence. Reading the experience and advice of others can make a huge difference to someone in a similar situation. If you would like to share your story with us, please register on our website. Go to www.continence.org.au/life-incontinence/personal-stories#sharestory

Unless otherwise indicated, the photographs used in Bridge are those of models and bear no resemblance to the story.

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NOTE FROM THE CEO

Welcome to the Spring edition of Bridge. I am pleased to announce that this Women’s Health Week we are forming a community partnership with Jean Hailes and running a National public relations campaign to raise awareness and provide information for women of all ages. Visit continence.org.au/womens_health_week

In celebration of Women’s Health Week, this edition focuses on pelvic health across a woman’s lifespan, from teens and young adults to pregnancy and post-partum, and menopause and beyond.

We are delighted to share with you the lived experience stories of incontinence from women in each of the three life stages, as well as the insights and perspectives from health professionals on treatment options and where to get advice and support.

According to a survey of more than 15,000 Australian women, less than two out of ten (17.6%) do their pelvic floor exercises daily, despite incontinence affecting one in three women who have ever had a baby. Urinary incontinence is the most common pelvic floor issue affecting women across their lifespan. We want to remind women of all ages there is a lot they can do to reduce their risk of incontinence. In many cases incontinence may be prevented, better managed, or even cured.

Whilst urinary incontinence is a topic most are familiar with, faecal incontinence carries with it much greater stigma. However, it is not uncommon in women who have had birth injury trauma and the good news is there is much that can be done about it.

Menopause gets a fair share of attention in this issue, and we speak to both a menopause specialist and urogynaecologist to understand exactly why women experience the myriad of often uncomfortable and bewildering symptoms which accompany this transition. It is great to see these, and many other topics previously not talked about now openly discussed. It is only through knowledge and education that we can make informed decisions about our health.

Please share this edition with everyone, especially the women in your life. Anyone looking for more advice and information about bladder, bowel and pelvic health can also phone the National Continence Helpline on 1800 33 00 66.

IN THIS ISSUE

Rowan Cockerell, CEO, Continence Foundation of Australia

Khan

Payam Nikpoor

process in a woman’s life

Sophie’s* story

my life

is a

CHRISTIN'S STORY

INCONTINENCE ISN'T JUST A SENIOR'S PROBLEM

When 24-year-old Christin Young walked into the urology clinic at a major Sydney hospital, she was struck by the fact that she was the only person under 30 in the room. “There was nothing to validate me as a young person experiencing incontinence,” she says. “There was no information at all about urinary problems in young people and I felt it reinforced that incontinence is an older person’s issue and it was not okay for me to be experiencing it.”

Christin experiences urinary incontinence that to date has not been medically diagnosed, despite undergoing every investigative procedure imaginable. “Lacking an official diagnosis has left a large question mark hanging above my head, even after years of medication, Botox, stress tests, ultrasounds, and other treatments,” says Christin. More recently she has been experiencing digestive symptoms, which for now have been placed under the umbrella of irritable bowel syndrome (IBS).

“The first time I remember leaking I was 16 and, on a train, making a big journey by myself. I was wearing my favourite jumpsuit and I remember it happened on the return trip and feeling wet and so embarrassed. Walking onto the platform on the way home I was sure everyone was looking at me and they knew,” says Christin. “It turns out it wasn’t a oneoff situation. It then became a continuous problem.”

Since then, Christin has worn sanitary pads every day and says she can’t go anywhere without being well prepared beforehand. “My incontinence is triggered by everything, particularly exercise, so I tend to be overly cautious,” she says. “The national public toilet map (NPTM) app has been a lifesaver for me. Every outing for me revolves planning around where the public toilets are, and I need to know there will be somewhere safe and clean to dispose of the pads.”

Christin also lives with paroxysmal kinesigenic dyskinesia (PKD), a distressing condition she developed at the age of 13 which presents visually in a way that can be mistaken for epilepsy but is not the same. While she says she was never embarrassed if she fitted in front of people, talking about, or revealing her incontinence filled her with enormous shame.

Christin Young, 24, from Sydney

After deciding to write her personal story of lived experience with incontinence, Christin says it took her two weeks to summon the courage to post it. “A few years ago, I wouldn’t have been able to talk like this,” she says, “but now I feel super proud of myself for sharing.” Encouragingly, the feedback and support she received was overwhelmingly positive, with many acknowledging her courage for ‘saying her truth.’ This has really raised Christin’s energy and her desire to reach out to others going through the same thing.

Christin would like to see and aims to be part of a support group for young people with incontinence to share their stories and experiences. In the meantime, she encourages young people to reach out to her and others who have shared their story. “There is no shame in being in the situation you’re in, but you need to process your insecurity and how you feel about it in your own time. Fear of shame and stigma is going to be different for everyone,” she says, “but never be ashamed of the things you don’t have any control of.”

DID YOU KNOW

THERE IS A NATIONAL PUBLIC TOILET MAP (NPTM) APP?

The National Public Toilet Map comes in very handy when you are travelling and need to use a toilet!

The National Public Toilet Map shows the location of more than 19,000 toilet facilities across Australia.

You can access the map via the National Public Toilet Map website at www.toiletmap.gov.au or by downloading the Toilet Map app available on Google Play or the App store.

The National Public Toilet Map provides:

6 The location of the nearest public toilet

6 Details of opening hours, accessibility, parking, and other features

6 The ability to add and update public toilets and their facilities.

The National Public Toilet Map is funded by the Australian Government Department of Health as part of the National Continence Program and is managed by the Continence Foundation of Australia.

“There is so much stigma for people my age dealing with this issue. I wish, as a younger girl, I knew that I wasn’t alone with incontinence within my age group, and there are many ways to live my life to its fullest despite it. My life could have been so much easier if I had someone to talk to about it.”

A passionate advocate for chronic illness and disability, Christin’s message is to live your life to the fullest despite it. “I’m hopeful that one day I’ll be able to effectively treat my incontinence, but until then, I plan to keep enjoying life the best I can,” she says.

goagainsttheflow.org.au

inconfidence.org.au

Scan here to download the map

PELVIC FLOOR MUSCLE HEALTH ACROSS A WOMAN’S LIFESPAN

This Women’s Health Week (WHW) the Continence Foundation of Australia has formed a community partnership with Jean Hailes and we are focussing on pelvic floor muscle health across a woman’s lifespan. This targets three important groups including teens and young women, pregnancy and post-partum and menopause and the years beyond.

Urinary incontinence (UI) is the most common pelvic floor issue affecting women across their lifespan and its prevalence increases with age. Whilst stress urinary incontinence (SUI) is predominant in younger women, overactive bladder (OAB) syndrome, also known as urinary urgency incontinence and a combination of the two is more common in older women, and the prevalence increases with each decade.

It is a common human trait not to think too much about our health until we experience issues. Young women in their late teens to early twenties are usually not too concerned about their pelvic floor muscle health, often thinking that incontinence is an older woman’s issue and not something they need to be worried about. However, more than one in ten young women experience bladder leakage (incontinence).

Although this can occur in any young woman, female athletes are particularly susceptible. Urinary incontinence, of which SUI is the most common, has a prevalence rate of 25.9% in young female athletes across different sports, with the highest prevalence rate of 75.6%. found in volleyball players.

An Australian study, published in 2018, found that 30% of female netballers experience urinary incontinence while playing one of Australian women’s most popular team sports. Published by women’s health continence physiotherapist, Naomi Gill, the study found that one third of all netball players, and half of those who have had children, experience urine leakage during training or playing the game.

Ms Gill hopes the study will also encourage the exploration into appropriate rehabilitation for women returning to sport after having babies. “As a profession we need to be looking at what information and guidelines are available for how to safely return to sport after having babies to reduce the risk of prolapse and urinary incontinence, and generally how to properly rehabilitate your body after pregnancy,” she said. You can read more at one in three netballers are incontinent

The association between UI and high-impact physical activity is due to increased pressure on the bladder. The good news is that pelvic floor muscle training (PFM) is considered to be the first line of therapy among young female athletes.

It is known that UI in young people is both underdiagnosed and under-reported. Many young women may not address the problem or seek specialist help due to embarrassment and lack of knowledge. They may also reduce or withdraw from physical activity due to fear of developing pelvic floor issues.

GO AGAINST THE FLOW

Go Against the Flow (GATF) was started with one main goal – to let young women know about incontinence; that it does happen, but it doesn’t have to. The research and co-design strategy is all about education, awareness, support, and sisterhood it’s about empowering young women to build a community where they can talk about ‘below the belt’ issues, starting with incontinence.

Like many women’s issues, there is something that can be done to treat incontinence and GATF is a website where young women can receive important information and support. The key message of GATF is that incontinence is both preventable and treatable and that it is not something a woman of any age should feel is a normal and irreparable part of her life.

GATF was created specifically for adolescent and young women as a primary prevention initiative with a long-term vision to curb the incidence of one in three women with incontinence and pelvic health issues later in life. For more information go to goagainsttheflow.org.au

PREGNANCY AND POST-PARTUM

The message is now loud and clear that women need to be thinking about the importance of their pelvic floor muscle health before they even conceive a baby! Evidence and the experience of healthcare professionals tells us that preparing the pelvic floor during pregnancy can reduce the likelihood of birth trauma injury and improve a woman’s post-natal recovery.

During pregnancy the body releases hormones that soften muscles, including the pelvic floor muscles. Along with the extra weight of a growing baby, this can weaken the pelvic floor and the organs it supports. Correctly doing pelvic floor exercises before, during and after pregnancy may help to reduce the chance of experiencing incontinence after birth.

During a vaginal delivery, the vagina stretches, and the supporting tissue and pelvic floor can tear. Women who give birth to larger babies, have a longer labour or difficult delivery are more likely to have bladder or bowel problems. Birth injuries such as pelvic organ prolapse (POP), and obstetric anal sphincter injury (OASI), also referred to as third- and fourth-degree tears, are likely to result in bladder and or bowel control issues.

Some women notice leakage (urine or stool) during pregnancy or after birth. It can take time for the pelvic floor and muscles to recover after birth, and every person is different. Most women notice their bladder and bowel concerns improve in the first six months after birth, but others may experience ongoing symptoms and require professional care and support.

It is not uncommon following birth for women to experience a shift in the attention of healthcare professionals from them to the care and wellbeing of the baby. Whilst this is a necessary focus, the care and wellbeing of the new mother in the immediate post-partum period is also vital, particularly if there has been significant birth trauma and/or injury. This requires informed and competent care, potential referral and a high level of support. Otherwise, women may face embarrassment, stigma and shame, particularly if their injury is followed by either urinary or faecal incontinence.

It is vital for women to have access to a supportive group where they can talk to women who have similar experiences and share information and strategies. This can help women to better comprehend their experience and incorporate it into the story of their journey. Download Pelvic Floor Health for Expectant and New Mums to learn more about the pelvic floor muscles and bladder and bowel control health.

For more information on safely exercising to support the pelvic floor muscles during pregnancy and after childbirth go to pelvicfloorfirst.org.au

MENOPAUSE

Much like we recommend preparing for pregnancy and childbirth, women also need to ideally consider their pelvic floor muscle health prior to menopause. Many women are ill-prepared for and poorly informed about the changes and symptoms they may experience during perimenopause and menopause. This can lead them to feel bewildered, scared, alone and ashamed.

Knowledge provides women with empowerment and often relief when they can attribute a cause to their symptoms, particularly loss of libido and greater susceptibility to urinary tract infections, which may often benefit from quite simple interventions.

The narrative around menopause is rarely positive, but this too is fortunately changing thanks to the information and communication boom that has seen the revolution of numerous podcasts tackling topics previously considered to be taboo, and the pioneering women and healthcare professionals who are making the changes that women want to see. Talking openly helps to reduce stigma and shame.

During the menopausal transition, the body produces less oestrogen which may contribute to changes in bladder and bowel health. The article “Menopause and Incontinence” (on page 19) explores the mechanisms which can lead to weaker pelvic floor muscles in more detail.

ANNA LENNIE

FLYING SOLO IN THE NT

On most working days, Anna Lennie’s first thought on waking is “I wonder what today will bring.” As the only pelvic floor physiotherapist in Central Australia, Anna describes her work as diverse, frequently challenging, and the conditions and people she treats often totally unexpected. A new day could bring her just about anything.

Based in Alice Springs Hospital, Anna currently works for Northern Territory Health, servicing communities throughout the region and extending across into South Australia and Western Australia. She has lived in Central Australia for over twenty years, seven of which were spent living and working part time within the Yuendumu community, 300 km northwest of Alice Springs.

Anna studied pelvic floor physiotherapy as an undergraduate at university when it was trialled during her final year. She knew immediately this was the work she wanted to do and initially worked alongside a continence nurse when she first moved to central Australia. She is currently the sole pelvic floor physiotherapist resource and is motivated by seeing the way treatment can change people’s lives. “I see people move from being isolated, depressed, and unable to go out due to their incontinence, to being able to experience a much better quality of life. It is very rewarding work,” she says.

Anna presented at the National Conference on Incontinence (NCOI) 2022 in Melbourne, where she shared her personal and professional experience as a service participant and provider, living and working in remote Central Australia. Her key message was that understanding the service participant's journey and context is vital to providing culturally safe and effective services.

The rates of incontinence are significantly higher in the Aboriginal population, up to 49%, and research shows this is well under reported. Risk factors such as diabetes, respiratory illness and obesity are also higher in the Aboriginal population. In addition, rates of gestational diabetes have been reported to be up to four times higher in Aboriginal women leading to higher birthweight of babies and associated increased risk of perineal tears.

Partnering with consumers requires planning and Anna has used consumer journey mapping to problem solve issues around access to pelvic health services for Aboriginal women based in remote communities, including the need to travel long distances to seek assistance and the other cultural and language barriers which may make access difficult.

Some of Anna’s main challenges in her work are the lack of resources and access to services in this remote and vast part of Australia. One of the great barriers she explains is our complex historical context and the associated trauma of racism for First Nations Australian people. This has sometimes led to a lack of trust in health services, particularly for more sensitive issues such as pelvic health.

Not surprisingly, a significant amount of Anna’s work involves education. Previously, she has been involved in women’s health ‘road shows’ to raise awareness and understanding of numerous health concerns. Anna also spent time working for NonGovernment Organisations (NGOs) in community, working with local Aboriginal women to provide education to young girls who were disengaged from high school. Closely guided by the senior Aboriginal women within these communities, each week they would present a different topic, from getting your first period, to dealing with consent, and domestic violence.

Now Anna uses Health Direct video conferencing to deliver over half of the pelvic health services to patients in urban and remote areas and works with Aboriginal health workers to try and broker relationships with the people she sees. Remote-based midwives, liaison officers and staff

“I see people move from being isolated, depressed, and unable to go out due to their incontinence to being able to experience a much better quality of life. It is very rewarding work.”

within Aboriginal Controlled Community Health Organisations will follow up with women after childbirth and work in partnership with her to ensure needs are met. Whilst many of us have taken telehealth for granted in recent times, Anna points out there is a lot to consider when using it in terms of finding safe cultural space.

All staff who work at Alice Springs Hospital undergo mandatory cultural safety training. Anna says, “the Aboriginal population make up over 70% of people we service, and we promote reflective practice around cultural competency, utilising Aboriginal liaison officers and Aboriginal co-workers to assist us with this.”

When asked about communication amongst First Nations women and whether storytelling is a part of how women pass on knowledge from one generation to the next, Anna is circumspect. “You can only tell a story that is your story,” she says. “Women’s business is exactly that and within Aboriginal culture can be extremely private. In my work I have always been guided by the female elders to ensure the education we deliver is culturally appropriate and respectful of situations in which assistance or intervention may or may not be desired,” says Anna.

KIMMY’S STORY

WOMEN NEED INFORMATION EARLY

A former elite athlete and corporate lawyer, Kimberley Smith was used to functioning at her peak. Like so many women, she was understandably shocked by the impact childbirth had on her body and so began her journey to return to exercise in a safe and positive way.

Kimberley was an elite athlete from the age of 18, attending the Australian Institute of Sport in Canberra straight out of high school. She played netball at the elite level for over 10 years, representing the NSW Swifts and was a member of the Australia Diamonds Squad. She says “at times I had leaking of urine at the end of a very hard training session, but I didn’t think much of it at the time. I just thought it was a sign my body had worked hard.” It was also a topic that none of the athletes discussed. Given the statistics on incontinence amongst female athletes, Kimberley says it is likely that at least two to three members of her team also experienced it, but no one talked about it. “In the sporting world we received so much information on nutrition, exercise and training, but the pelvic floor was never mentioned. I would love to see that change,” she says.

Heavily pregnant with her first child in 2012, Kimberley said she was in the middle of a shopping centre when she sneezed and completely lost control of her bladder. “I was so embarrassed,” she says, “but I still didn’t think too much about it or see it as a red flag.” Following a long labour and giving birth to a large baby, Kimberley knew something was wrong. She had a grade two cystocele prolapse and went back to the hospital to seek advice and support one week after giving birth. When told that her pelvic floor looked normal, she sought another opinion. Kimberley was fortunate to then meet Titled Women’s Health Physiotherapist, Lyz Evans, who supported her recovery with pelvic floor muscle retraining and exercise.

Kimberley’s post-natal goal was to get back into the high level of exercise that had always been a huge part of her life, and she wasn’t going to let incontinence get in the way. It wasn’t until after the birth of her second baby that what she had previously experienced as stress incontinence became urge

“In the sporting world we received so much information on nutrition, exercise and training, but the pelvic floor was never mentioned. I would love to see that change.”

Kimberley Smith and her daughters

incontinence as well, and the incontinence overtook the prolapse as an ongoing health issue.

With a third baby and the impact of each pregnancy on her pelvic floor, Kimberley says her incontinence slowly increased in frequency over time to the point where it was affecting her quality of life almost every day. “I couldn’t predict when it would happen,” she says. “I could do a big training session and have no leakage at all, then wet myself when I just went to put my shoes on. It was random, so frustrating, and obviously the reasons behind it were complex.”

Kimberley’s journey has been a long and challenging one in which she has modified her lifestyle substantially and accepted that she can no longer do all the high intensity exercise she was able to do before. Her body had changed, and her pelvic floor had dictated that she needed to adjust accordingly.

“Women need information early and they need so much more,” she says. “A woman needs to know about the reality of childbirth and what can happen. Then she needs to be prepared with proactive strategies to assist with labour, birth, and postpartum. Giving birth is one of the most incredible things our body can do, but the impact and repercussions are just not talked about enough.”

Kimberley’s passion is to see quality exercise and health education readily accessible and affordable for all women. She would also like to see more nuanced conversations about living with and managing incontinence long term. “One of the things that bothers me is that we laugh and joke about Mums wetting themselves when they jump on the trampoline, but I think this sends out the message that incontinence is normal,” says Kimberley. “The message that incontinence is common, but not normal is a step in the right direction, but it fails to share that there is so much that can be done to help reduce or manage incontinence. Anyone who experiences incontinence should see it as a warning sign and a red flag telling you to get onto this and do something about it now. Don’t accept being told ‘everything is fine’ if it doesn’t feel that way to you. Always seek a second opinion,” she says.

Kimberley is also concerned that women are told to “just do your pelvic floor muscle exercises” but says incontinence often requires a much more nuanced approach. Some women will experience incontinence due to a hypertonic (overly tight) pelvic

floor, while others will experience incontinence because of an overactive bladder. Without proper guidance and education, you might never fully understand the root cause of your leaking. A Pelvic Health Physiotherapist or Nurse Continence Specialist can provide this guidance and support. Kimberley’s passion led to the launch of the Empowered Motherhood Program with co-founder and physiotherapist Lyz Evans. This is a complete online program for every stage of the pregnancy and postnatal journey, with physio-led exercise and education, including a specialised prolapse program for women with prolapse or weak pelvic floors. For more information go to empoweredmother.com.au.

WHAT IS A GRADE TWO CYSTOCELE?

A cystocele is a prolapsed or fallen bladder, which can occur after a vaginal birth when the ligaments that support a woman’s bladder and vagina become stretched or weakened, resulting in the bladder sagging into the vagina. There are three grades of cystocele which include:

Grade 1 (mild) – the bladder drops slightly into the vagina

Grade 2 (moderate) - the bladder drops to the opening of the vagina

Grade 3 (severe) – the bladder bulges through the opening of the vagina

THE BLADDER BEFORE AND AFTER PROLAPSE (CYSTOCELE)

HERE FOR WOMEN THROUGH THE LIFE STAGES

LYZ EVANS TITLED PELVIC HEALTH PHYSIOTHERAPIST

Clinical Masters: Women’s Health & Continence. B.App.Sci: Phy.

TELL ME ABOUT YOUR WORK AND THE IMPORTANCE OF PELVIC FLOOR HEALTH ACROSS THE LIFESPAN

I am here for women through all the life stages. Most commonly, a woman will present to me for the first time whilst she is pregnant or needs guidance after childbirth. However, it is important that we get the message out that looking after your pelvic health is critical across a woman’s entire life span, commencing in childhood all the way through to the post-menopausal years. If pelvic floor, bladder, and bowel function is optimised in childhood, her

rates of pelvic floor dysfunction later in life will be significantly reduced.

The other important message for women is that the period between having your children and reaching menopause is a critical time to focus on building up your pelvic floor muscles. Once a woman becomes menopausal, it is more challenging, but not impossible to build muscle bulk. If a woman can enter the perimenopausal years with a strong well-functioning pelvic floor she is far less likely to experience symptoms later in life. Many women are surprised when they reach menopause to suddenly experience symptoms such as wind incontinence, faecal smearing, urinary incontinence and prolapse.

This can be bewildering for a woman who may have gone through her childbearing years without too much pelvic floor trouble and was not expecting this sudden onset of new symptoms.

Lyz’s key area of research and expertise is obstetric anal sphincter injury (OASI). Defined as damage to the anal sphincter muscles which occurs during childbirth, OASI is also referred to as third- or fourth degree tears and is a major contributing cause of anal incontinence for women following childbirth and in the menopausal years.

Whilst working as a pelvic floor physiotherapist at the Royal Women’s Hospital in Sydney, I clearly remember one of the first patients who had a long-lasting impact on me. Ashani* had recently given birth to her first baby during which she had sustained a fourth-degree tear that did not heal well. She was understandably traumatised by the birth and experienced ongoing faecal and flatulence incontinence as well as pain. The impact of Ashani’s* experience prevented her return to work in a factory where employees were only permitted two toilet breaks per day, something she knew would be impossible for her. Her inability to work and be intimate with her husband put significant strain on the relationship which eventually broke down.

HOW DID YOUR INTEREST IN OBSTETRIC ANAL SPHINCTER INJURY (OASI) DEVELOP? WAS IT SOMETHING YOU SAW A LOT OF AT SYDNEY ROYAL WOMEN’S HOSPITAL?

Lyz Evans, Titled Pelvic Health Physiotherapist

Stories like Ashani’s* illustrate not just the immediate impact of birth trauma, but the ongoing physical, mental and emotional effects. This led me to my own research on the long-term impact of OASI, which showed the substantial influence on a woman’s future birth choices, sexual and bowel function, quality of life and mental health issues.

My research revealed that women were without doubt suffering and for a longer period of time than was previously accepted. The physical impacts of giving birth can run deep and seep into so many areas of her life. We found that over 50% of women were suffering from symptoms the average individual would deem unacceptable, at an average of four years post birth. Of these, 51% were experiencing ongoing bowel issues, 46% reported quality of life impact, 25% reported mental health issues, 19% had to alter exercise, 45% reported an impact on family planning, and 10% decided to have no further children because of the tear. I think these findings are staggering, and more needs to be done to not only support these women but prevent them from happening in the first place.

for third- and fourth-degree tears that was released last year by the Royal Australian Commission on Safety and Quality in HealthCare. It Identifies seven key areas to assist in the prevention and identification of third- and fourth degree tears and provides recommendations for follow up support such as pelvic health physiotherapy. There is still a long way to go, but this really is a great step in the right direction and should result in better outcomes for women that do sustain a third- or fourth degree tear. The data on the incidence of third- or fourth degree tears looks to be reducing which is really promising.

WHAT COULD STILL BE IMPROVED?

Currently, birthing women will have a six-week post-natal check with their midwife, obstetrician or GP. In this appointment everything from wound recovery, feeding, vaccination, mental health to family planning is covered. Women need to be given Medicare funded access to a pelvic health physiotherapist as part of routine care. My professional body, The Australian Physiotherapy Association, is currently working hard on petitioning the federal government to do this.

I think we are at a crisis point. Birth trauma rates are high, women are often birthing in a fearful state with very little follow up support. Healthcare providers are doing an incredible job with the resources they have; however, the system is stretched, and we are not adequately funded to provide women with what they really need during pregnancy, birth or the post-natal year. Women need to be provided greater support and education along the entire journey and have access to a pelvic health physiotherapist who can work with them to prepare their pelvic floor for birth during pregnancy and help them recover optimally post birth.

The cost of incontinence and prolapse continues to rise and places a significant toll on health care expenditure each year. The time has come that we need to wake up and start doing more to prevent birth trauma happening in the first place.

Whilst there hasn’t been a huge change in access to support such as government funded pelvic health physiotherapy and psychology for birthing women, there has been a wonderful Clinical standard of Care

WHAT ARE THE MOST IMPORTANT QUESTIONS TO ASK A POST-NATAL WOMAN WHEN SHE COMES TO YOU FOR HELP WITH PELVIC FLOOR ISSUES?

I am very aware that I may be the only person who ever sees a woman for her pelvic floor, so I consider it my duty of care to ask her everything to give her the opportunity to share in a safe space what is going on with her body that she may never have told anyone. I help women realise they are not the only ones, and that there is a lot that can be done to help.

I run a clinic in Sydney called Women in Focus Physiotherapy and we see it as a team effort to ensure the woman feels comfortable from the minute she arrives. Once in the consultation room

I explain that I am there to hear her story and want to hear in her own words why she has come to see me. I tell her that I am going to ask many detailed questions about her bladder, bowel and sexual function and not to be embarrassed. I let her know that nothing will shock or surprise me, I’ve heard it all, as issues with the pelvic floor, bladder and bowel are more common than you think. The more I know, the more chance I can help.

YOU IDENTIFIED A GENERAL LACK OF FOLLOW UP CARE FOR WOMEN AFTER CHILDBIRTH. HOW DO YOU THINK THINGS HAVE CHANGED FOR THE BETTER?

WHAT DO YOU DO TO MAKE A WOMAN FEEL AT EASE WHEN HAVING A VAGINAL EXAMINATION?

I will always try to communicate clearly during the consultation and let her know that she is in charge.

I might say to a woman, based on the information you have given me, I need to know more about your pelvic floor function, and this may involve a vaginal examination. We may start with an ultrasound, but this only shows if a muscle lifts and lets go. It doesn’t tell us anything about the tone or strength of the muscles and whether there is a prolapse, avulsions, skin conditions, spasm or tears.

If a woman is not comfortable having a vaginal examination, that is absolutely fine. It is her body, her choice, and I will do my best with the information I have. I will also her ask about any history of sexual trauma or abuse prior to the examination as its important for me to know if the appointment could be a particularly difficult, triggering, or traumatising experience for her.

herself the rest, care and support she needs to recover.

One of my key messages to post-natal women is please don’t race back to pounding the pavement too quickly! Your body has changed, and it won’t just automatically switch back to being able to do what it did before pregnancy and childbirth.

Over the course of nine months, a woman’s body has physically and hormonally changed. Childbirth is quite possibly the biggest physical impact your body has endured. To be able to birth a baby’s head, the pelvic floor needs to extend by three times its normal length during labour. It then takes time for the pelvic floor and abdominal muscles to shorten, strengthen and function well enough again to support a woman to do impact exercise.

I refer to the first three months after birth as the ‘fourth trimester.’ This is a time when everything is still open and soft and a woman needs to give

The pelvic floor is hidden from view, so most people don’t think about it until something is wrong. Just like you wouldn’t continue running if you get knee pain, incontinence is telling you to stop because something isn’t quite right. It’s important for women to realise that if they are exercising before these muscles are ready, they are increasing the risk of prolapse and incontinence. Instead, it is important to start with foundational exercises first, then build on this with progressive functional loading. You need a graded exercise program that is tailored to each individual body.

The Empowered Motherhood Program (EMP) focuses on educating women about birth in a fully informed way. We have videos where we discuss many of the potentially ‘scary’ things, for example explaining what forceps are and where they might be needed so a woman is not seeing them for the first time during labour. I strongly believe that women should not be given information for the first time in the throes of labour when they are required to make a decision that could impact them for the rest of their lives. Women are intelligent capable beings who do not need to be in wrapped in cotton wool. I truly believe that if a woman is educated in an empowering way and able to prepare her pelvic floor for birth, it will have a huge impact on her birthing experience. For more information go to empoweredmother.com.au

The EMP has an exercise and education program for women from the beginning of pregnancy to 12 months post-natal. In the Birth Preparation series, we have taken a three-pronged approach. Firstly, we prepare the woman mentally, so she feels fully informed. Then we teach her how to prepare her body physically for birth. She learns how to open, relax and lengthen the pelvic floor which is required during birth. From 34 weeks gestation we focus on teaching women how to ‘down train’ their pelvic floor muscles, including the importance of deep pelvic floor release and perineal massage. We also teach women how to push the right way, which can be crucial to help prevent third- and fourth-degree tears.

Lastly, we want to help women prepare emotionally and remind them that their body is designed to birth. If they can trust their bodies’ innate birthing wisdom and the incredible hormones that help the process of childbirth, women have put themselves in the best position possible.

WHAT IS YOUR ADVICE FOR POSTNATAL WOMEN WANTING TO RETURN TO EXERCISE, PARTICULARLY IF THEY WERE VERY ACTIVE BEFOREHAND?

YOUR EMPOWERED MOTHERHOOD PROGRAM IS DESIGNED TO HELP WOMEN RECOVER FROM BIRTH IN A SAFE AND POSITIVE WAY. CAN YOU TELL ME ABOUT SOME OF THE KEY ELEMENTS OF YOUR BIRTH PREPARATION PROGRAM?

The concept of leaking urine is something many women have experienced in their life and is far more broadly discussed, so definitely has less of a “taboo” tag associated with it than anal incontinence. Anal incontinence, which is the involuntary leaking of solid stool, liquid stool or gas is far more common than realised. Childbirth, a history of constipation and obesity are the most significant contributing factors. If a woman reports any symptoms of anal incontinence, I will explain the bowel, rectal and anal sphincter function so she has a good understanding of the biomechanics and therefore what may be causing the problem.

When someone is experiencing anal incontinence, we need to think about how their anal sphincter may be functioning. I would discuss with her the gold standard of care would be to do a rectal examination to really assess the sphincter muscles and the puborectalis muscle of the pelvic floor.

I would explain that I am assessing the muscle tone, looking for any major or minor sphincter tears, scar tissue, anal reflex, and the coordination of the muscles. Treatment really does depend on the examination findings but may include a bowel diary, dietary changes, defaecation dynamics, anal sphincter and pelvic floor training, rectal balloon and rectal sensitivity training and electrical stimulation if appropriate. These all sound quite full on, but most women are incredibly grateful to be able to participate in some treatment to help a problem that is affecting their quality of life.

ANY FINAL WORDS YOU WOULD LIKE TO SHARE?

The saying ‘you don’t know what you’ve got till it’s gone,’ rings true for the pelvic floor. Many women I see have taken their pelvic floor for granted. That is of course until something changes and then they are devastated they didn’t do more to prevent it by being proactive. So, my parting words would be, if you have never been to see a pelvic health physiotherapist no matter what life phase you are in, do yourself a favour, invest in your health and book that appointment now!

* Name has been changed to protect privacy

WE TEND TO HEAR A LOT ABOUT URINARY INCONTINENCE, BUT ANAL INCONTINENCE IS ASSOCIATED WITH MORE STIGMA. HOW DO YOU HELP WOMEN DEAL WITH THIS AND WHAT DOES YOUR APPROACH TO TREATMENT INVOLVE?

AMANDA’S

STORY

I ALWAYS WENT ‘JUST IN CASE’

Amanda first noticed bladder weakness, manifesting as urinary urgency and frequency, after the birth of her first child. At the time she thought it was just something she had in common with several of the women in her mother’s group. “This is when I started the ‘I better go just in case’ routine because I didn’t want to be out and wet myself,” says Amanda*

Two years later and after the birth of her second child, Amanda* noticed the problem had become worse. After confiding in her sister, she discovered there were treatment options for women, one of which was an artificial compression device, also known as a balloon, which is used for mild to moderate stress incontinence. This had been “the best thing ever” according to Amanda’s sister, so Amanda decided it was time to consult a urogynaecologist.

Following a diagnosis of stress urinary incontinence (SUI), Amanda's urogynaecologist recommended an operation was a better option for her than a balloon. Amanda* went ahead with the procedure and experienced a good outcome with no further continence issues for many years. And then, she hit menopause….

With the onset of menopause, Amanda noticed she had continence issues again. “I was experiencing what I know now was urge incontinence,” says

Amanda. “My keys would literally just be in the front door, and I was like get out of my way and bolting to the toilet. We used to laugh about it but then I realised I didn’t actually have to put up with it.”

Amanda decided to again consult her urogynaecologist as she wondered if the previous operation was no longer effective. She was asked to complete a bladder diary, which revealed she urinated more frequently than normal and was now experiencing urge incontinence (UI). Her urogynaecologist advised Amanda she had three options: see a pelvic floor physiotherapist, consider Botox treatment, or take medication. Amanda went for option number one and headed off to see a pelvic floor physiotherapist who assessed her pelvic floor muscle function and prescribed an exercise programme to retrain these muscles.

Amanda says one of the key factors in retraining her pelvic floor muscles has been to focus on techniques which divert her brain from responding to the urgency need. Her physiotherapist advised her not to ever run to the toilet, but stop first, stand, walk slowly, and delay the process as long as reasonably possible. Other diversionary techniques she has found useful include curling her toes and tapping when she feels the need to urinate, again distracting the brain from the urgency signal.

Amanda finds she can now ‘hold on’ for a lot longer and has stopped going to the toilet ‘just in case.’ Whilst remembering to do her pelvic floor muscle exercises daily requires ongoing selfdiscipline and commitment, Amanda* has definitely experienced improvement. “I feel like I have a better understanding that there are two types of incontinence and I get the difference between the causes of them,” she says.

*Name has been changed to protect privacy.

MENOPAUSE AND INCONTINENCE

Hmm menopause…. hot flushes, mood swings, low libido, insomnia, night sweats, but wait there’s more! A lesser-known fact is that overactive bladder (OAB) syndrome is also more likely in postmenopausal women aged 45 to 54 years. This can result in a sudden urgency to sprint to the loo and often!

Like many health conditions, the topic of menopause is often surrounded by a wall of silence. Numerous women experience embarrassment and discomfort around talking about their menopause symptoms and unfortunately don’t seek help for something that is manageable. However, “when women do speak out, they soon discover that other women are going through similar experiences and are often greatly relieved to know they are not alone,” says Janie Thompson, Clinical Services Manager for the Continence Foundation of Australia’s National Continence Helpline (1800 33 66 88).

Common barriers to women seeking help include stigma and shame, a belief that symptoms are a normal part of ageing, cultural and language difficulties, lack of access to trained healthcare providers and lack of knowledge of available treatment options.

Incontinence is experienced by over 55 per cent of postmenopausal women, with rates increasing

significantly after 60 years of age. However, it is important to emphasise that incontinence is not a normal consequence of ageing.

Lower urinary tract symptoms (LUTS) are experienced by nearly one in three women and are associated with a significant negative impact on quality of life. LUTS is a broad term which includes urinary urgency, frequency, and lower urinary tract pain, as well as voiding dysfunction. Despite the high prevalence and negative impact of LUTS less than 25 per cent of women seek help.

Janie says that whilst stress urinary incontinence (SUI) is the most common type of incontinence experienced by women, OAB can be more obvious after menopause, and can cause more anxiety because of having the sudden urge to go to the toilet.

“OAB is characterised by urinary urgency or rushing and is usually accompanied by increased daytime frequency or going to the toilet more often and/or nocturia or waking to go to the toilet at night, and you may have urinary incontinence on the way to the toilet. Your bladder wants to empty suddenly without a lot of warning,” says Janie.

By contrast, SUI is the unintentional loss of urine due to effort or physical exertion, including exercising, sneezing, and coughing and your pelvic floor or urethra (bladder tube) are unable to prevent this leakage due to weakness or changes. It is often due to the combination of pregnancy, childbirth, being overweight, straining to use your bowels and having weakened pelvic floor muscles. You can have both these types of incontinence at the same time.

HOW DOES MENOPAUSE IMPACT BLADDER AND BOWEL HEALTH?

During the menopausal transition, oestrogen levels decline dramatically, which may lead to a thinning and weakness in the tissues of the pelvic floor and bladder, which normally depend on a regular and healthy supply. Vaginal dryness, due to reduced oestrogen, can also affect the tissues of the urethra. As such, many women notice changes to their bladder and bowel health, including:

REDUCED BLADDER CAPACITY

As women age, the bladder can start to hold less and not empty as well. As the bladder fills with urine, this loss of bladder flexibility and volume may cause you to go to the toilet more often. Combined with weaker pelvic floor muscles, this makes it much more difficult to hold on or put off going to the toilet.

A WEAKER PELVIC FLOOR

An inevitable consequence of the aging process is loss of muscle mass due to oestrogen and collagen deficiency, and the pelvic floor muscles may become thinner and weaker. This can lead to urinary or faecal incontinence as we use our pelvic floor muscles to help control our bladder and bowel, urine leakage with coughing and sneezing, or urgency and frequency.

Given the abundance of oestrogen receptors in the urogenital tract, it is not surprising this natural reduction of endogenous estrogen can cause or potentiate pelvic floor muscle issues and recurrent urinary tract infections (UTIs).

VAGINAL DRYNESS

Oestrogen helps maintain the surface moisture of the vagina and urethra. With less oestrogen in the body, the vagina and urethra (bladder tube) can become drier. This can be painful and irritating, especially with sexual intercourse, increasing the risk of urinary tract infections (UTIs) and incontinence.

PROLAPSE

Some factors, particularly childbirth and a weaker pelvic floor, mean pelvic organ prolapse (POP) is more likely to occur after menopause. POP occurs when one of the pelvic organs sags and may bulge or protrude into the vagina. There are different types of POP, and it is important to have any prolapse properly assessed. The most common symptoms of POP are the feeling of a lump in the vagina, vaginal heaviness or pressure, difficulty emptying the bladder or bowel and lower back pain. Not surprisingly this can cause embarrassment, anxiety, fear of going out and avoidance of exercise and social situations.

SYMPTOMS FROM CHILDBIRTH

Some women may experience damage to their anal sphincter during birth, but the symptoms might not be obvious until later in life. Faecal incontinence due to this damage most commonly starts in perimenopause, when hormonal changes may lead to the development of symptoms.

RECURRENT URINARY TRACT INFECTIONS AND DYSPAREUNIA

Microbial changes in the vagina associated with menopause include increased vaginal pH as a result of reduced oestrogen levels, which leads to a decrease in the usual lactobacillus dominant vaginal flora seen in premenopausal women. This increases the potential for pathogenic microbes like E. coli and Enterococcus, most commonly associated with UTIs, to populate in the vagina.

Figure

oestrogen

in

female pelvic organs

tissues.

EARLY MENOPAUSE

Early menopause means going through menopause before the age of 45. Early menopause can happen after medical treatment such as removal of the ovaries and chemotherapy for cancer.

PERIMENOPAUSE

Perimenopause refers to the years leading up to menopause where there is a drop in female sex hormones, namely oestrogen, which may fluctuate.

MENOPAUSE

Menopause marks the last period or menstrual cycle a woman has.

POST MENOPAUSE

Usually refers to the time after a woman has gone through menopause; 12 months after her last menstrual period.

SO, WHAT CAN BE DONE?

According to Janie Thompson, improvement can start with making the workplace more conducive to menopausal women’s comfort. “Employers can make sure simple things like good ventilation, regular breaks to help with fatigue and providing toilets that are easily accessible is all in place,” she says.

There are also many treatment options available for menopause and incontinence, and women don’t have to just put up with the symptoms and inconvenience. For incontinence, these may include pelvic floor muscle training, bladder training, vaginal oestrogen cream or an oestrogen pessary, lifestyle changes and surgery. For more information and to speak confidentially to a Nurse Continence Specialist, call the National Continence Helpline on 1800 33 00 66.

The Foundation also has a lifesaving toilet help card available for those who often find themselves caught out and in need of urgent access to a toilet.

Download toilet help business card

Download Menopause Fact Sheet

For more tips on managing menopause in the workplace go to Jean Hailes.

CULTURAL PERSPECTIVES ON MENOPAUSE

Women’s experience of menopause is highly influenced by cultural attitudes and beliefs towards menopause and menopausal symptoms, as well as socioeconomic and lifestyle factors. A comparison of the menopausal experiences of several ethnic groups reveals some enlightening and interesting differences.

Menopause and its accompanying symptoms tend to be highly medicalised in the Western world. However, this time of life should be viewed as an important opportunity for self-care and perhaps a change in lifestyle habits that are no longer useful or health-enhancing.

According to Traditional Chinese Medicine (TCM), menopause or juejing is regarded as a natural part of the ageing process and is seen as a deficiency of kidney yin, which requires balancing and nourishment with food and herbs.

The Japanese have no equivalent word for the phrase ‘hot flush’, and the word to describe menopause is ‘konenki’ which is not a direct translation, but a word made up of three parts reflecting energy, regeneration, and renewal. In Japan this ‘time of life’ is about transition and a new purpose.

In Islamic, Indian, and most African societies, postmenopausal women may enjoy greater social freedom as they no longer have to observe strict gender roles.

The Indian Ayurvedic system of medicine ‘views menopause not as a disease but as a transition period. It is a very important time in a woman's life where she has an opportunity to prioritise care for her health and wellbeing in all aspects –physically, mentally, emotionally, sexually, and spiritually.’

Native American women do not have a single word for menopause and regard the menopausal transition as a neutral or positive experience, considering postmenopausal women to be ‘women of wisdom.’

Generally, Aboriginal and Torres Strait Island women consider “menopause” to be a European word. Research demonstrates they tend to be more comfortable with “Change of Life” or “The Change” indicating their recognition of menopause as a ‘natural’ life transition, in which biological assistance or intervention may not be desired.

The change was described by one postmenopausal woman as “a process of ageing, like a ring around a tree”. There is no specific indigenous language term or phrase for menopause, and it appears not to be a culturally significant event. However, women do gain greater status with their menopausal transition.

Mayan Indian women from Mexico

experience very strict boundaries and taboos around food and activity whilst they are menstruating. Menopause therefore allows them greater freedom and is thus often positively awaited.

Disclaimer: these findings are not intended to be generalised to all women of the cultures mentioned in recognition of the considerable diversity within these populations.

DR FATIMA KHAN - MENOPAUSE SPECIALIST

MBBS, BSc, DRCOG, MRCGP, FRACGP

WHAT ARE SOME OF THE KEY SIGNS OF PERIMENOPAUSE?

Perimenopause can begin anywhere from five to eight years before menopause and women may start to experience symptoms from their early 40s. The early signs of perimenopause are changes in the menstrual cycle, which may become heavier, lighter, longer, or shorter, changes in mood such as irritability, anxiety or low mood, and other physical symptoms such as hot flushes, night sweats and sleep disturbances. Women often feel they are the only one going through this and can tend to feel isolated and ashamed.

Unpredictability in mood occurs because hormone levels are changing. Low mood and anxiety or mood disturbances can be early symptoms of perimenopause which is under recognised and women may be diagnosed as depressed and put onto antidepressants. Menopause is defined as the last menstrual period and the average age of onset is 51.

WHY DO YOU THINK WOMEN MIGHT BE RELUCTANT TO SEEK HELP FOR MENOPAUSAL SYMPTOMS?

Many women believe their symptoms are just something they need to put up with because that’s what we’ve been conditioned to do, and because we don’t talk about it, women don’t necessarily understand it. Another reason is women may be embarrassed or uncomfortable talking about symptoms like low libido and a dry vagina. There is also a lot of stigma and shame attached to this stage of life, as it is just not spoken about.

We need to have a more positive narrative around menopause and encourage women to seek answers and support. Whenever we don’t talk about things openly there is a lot of shame and shame leads to isolation. The impact of menopause on emotional and mental health is just not discussed.

The classic symptoms of hot flushes and night sweats, most women can find ways to deal with. But it’s the mental health aspect that bothers many women – anxiety, depression, low mood, low energy and motivation and the cognitive symptoms that really impact women’s ability to function. Common cognitive symptoms include brain fog, reduced concentration, forgetfulness and losing words mid-sentence.

The short-term goal is quality of life. I ask women how are you functioning? Are you functioning to your best ability at home and at work? Are you functioning as a mother/partner/colleague? If a woman is not, then she needs help.

SOME WOMEN DESCRIBE THE SUDDEN RETURN OF ANXIETY AND DEPRESSIVE SYMPTOMS DURING MENOPAUSE LIKE BEING HIT BY A FREIGHT TRAIN! IS THIS A COMMON EXPERIENCE AND WHY IS IT SO INTENSE?

I like to say that hormone health is mental health. This is because of the direct impact of our hormones on our mental and cognitive function. The decline in oestrogen, testosterone and progesterone can impact many aspects of our daily function.

During menopause, it is not uncommon for oestrogen levels to drop massively and quickly. I have seen them go from around 200 pmol/L down to about 20 pmol/L within a week, and yes, this could explain the suddenness and severity of symptoms a woman experiences. Due to the sudden decline in oestrogen levels this can trigger all manner of symptoms. Many of my patients are very relieved when I tell them the way they are feeling is due to the state of their hormones and that it is likely to be temporary.

Dr Fatima Khan, MBBS, BSc, DRCOG, MRCGP, FRACGP

"Whenever we don’t talk about things openly there is a lot of shame and shame leads to isolation.”

Oestrogen is a fundamental resource for the female brain and is needed for cognitive function, decision making and concentration. Oestrogen is also directly linked to serotonin – our “happy hormone.” The significant drop in oestrogen during menopause has a major impact on both mood and sleep, and disturbed sleep affects brain function as well. No wonder women experience brain fog, memory issues and can’t think clearly! We do of course adapt over time, but the initial symptoms can be frightening and bewildering for many women.

Some women worry that the brain fog, forgetfulness, and difficulty finding words mid-sentence could be an early sign of dementia, but it is important to remember that menopause is not “all in your mind.” Menopause is a time of huge physiological change. It is not in your mind. The physical and emotional symptoms can be very debilitating and sometimes frightening for many women.

WHY DO YOU THINK MENOPAUSE IS SUCH A TOUGH TIME FOR SO MANY WOMEN?

There is a lack of awareness and education so many women are unable to recognise their symptoms. They are also unaware of choices and don’t know where to seek help and are often embarrassed to talk about it.

Normally, when transitioning through menopause, a woman will have a reserve supply of oestrogen from her adrenal glands and fat cells. This is why there is a natural increase in fatty tissue around the tummy – nature’s way of protecting us. However, women worry if they gain weight, so they go out and do more exercise which places even more stress on the body. From the ages of 40 to 60 years, women tend to gain half a kilogram per year and the hormonal change around menopause increases the fat distribution around the abdomen. We also lose muscle mass with age and our metabolism can slow down, particularly if we become more sedentary. Not surprisingly in our image obsessed culture, these changes can affect a woman’s body image and self-esteem.

When oestrogen levels decline, especially one to two years post menopause, women can experience vaginal dryness and urinary frequency. The term for this is the genitourinary syndrome of menopause. This may present as vaginal dryness and for some women, itchiness, recurrent urinary tract infections and urge incontinence. Vaginal dryness can also lead to painful sexual intercourse which may impact relationships. Women can use vaginal lubricants prior to intercourse, and for many women localised vaginal oestrogen or using moisturisers regularly will help relieve their symptoms.

This is a really important time for women to focus on their pelvic health, which includes bladder and vaginal health. Women need to make sure they do their pelvic floor muscle exercises regularly and Pilates is excellent for strengthening the pelvic floor muscles as well.

*Urge incontinence is the involuntary loss of urine associated with urgency, that is a sudden and strong need to urinate.

The other issue is that so many women reaching menopause are “burnt out,” their adrenal glands are depleted, and their sympathetic nervous system is in overdrive. Generally, the lifestyles we lead mean we have chronic, elevated cortisol making the menopausal transition harder. Women’s menopausal

YOU EXPLAIN THAT THE DECLINE IN OESTROGEN DURING MENOPAUSE CAN SIGNIFICANTLY IMPACT MEMORY AND LEAD TO BRAIN FOG AND FORGETFULNESS. CAN YOU ELABORATE ON THE MECHANISMS FOR THIS?

CAN YOU DESCRIBE THE IMPACT OF MENOPAUSE ON CONTINENCE AND THE PHYSIOLOGICAL REASONS A MENOPAUSAL WOMAN MAY EXPERIENCE OVERACTIVE BLADDER AND/OR URGE INCONTINENCE *?

"Menopause is a unique journey for every woman with a different pathway for each.”

symptoms are then more severe because they don’t have the adrenal reserves they need.

There are so many changes women must contend with and there is no manual telling you what to do after the age of 50. I see this as a window of opportunity, a time to evaluate, reprioritise your life, put yourself on top for once and reset. And this means emotionally and mentally as well as physically. We are so socially conditioned to be caregivers for our whole lives, this is a time when a woman can make sure everything she does aligns with her own personal value system. This is often a time when women decide they can finally say ‘no’ and write their own manual on how they want to live the rest of their lives.

WHAT IS THE SYMPATHETIC NERVOUS SYSTEM?

The sympathetic nervous system (SNS) is part of the autonomic nervous system (ANS) and is activated as our involuntary response to stressful and dangerous situations, known as our “fight-orflight” response. It works with the parasympathetic nervous system, which calms us down, to maintain our baseline and regular body function. When the SNS is switched on our adrenal glands release the stress hormones adrenaline and cortisol, which produce the symptoms we associate with stress such as sweating, rapid heartbeat and shortness of breath. When the SNS is constantly switched on we remain in this hyperalert stage which can lead to chronic stress, depression, and anxiety.

Our social conditioning means there is no visibility and representation of women in midlife, especially in the media. There is so much more isolation, but older women have so much to offer. In other cultures, when a woman gets older, she is seen as someone you go to for advice, a valued and respected member of her society. It is also okay for women to become a bit plumper and round. I am from an Asian background and that is how it was for my Aunties, none of whom experienced severe menopausal symptoms.

Menopause is not the end, it’s the beginning and can be the most liberating time in a woman’s life; the reproductive burden is gone, she is no longer menstruating and having to look after children. I think with the right mindset and support women can go on to live their best life.

DR KHAN’S ADVICE FOR A HEALTHY MENOPAUSAL TRANSITION:

like-minded women and have good, positive social connections and support.

"We’ve lost the ability to adapt easily. We reach menopause without the reserve we need. On top of this we have processed diets, don’t exercise properly, sleep less and we are chronically stressed”

DR PAYAM NIKPOOR MENOPAUSE IS A BIG PROCESS IN A WOMAN'S LIFE

UROGYNAECOLOGIST MD, FRANZCOG, CU

By Nicola Reid, Media & Content Health Writer, Continence Foundation of Australia

INTRODUCTION

Sometimes you just need someone to help you connect the dots and this is exactly what Dr Payam Nikpoor did for me. As a woman navigating the often weird and bewildering transition that is menopause, I just needed to understand the mechanisms behind what was happening to me.

Dr Nikpoor is a warm and gentle man who has profound insight, experience, and empathy for women and the many challenges they face across their life span. He has particular sympathy for the impact menopause can have on a woman’s confidence and self-esteem and believes that as a society and community greater awareness of what women are experiencing through menopause may bring more compassion and understanding.

Dr Nikpoor, who insisted I call him Payam, was very generous with his time and his knowledge and had a way of conveying information clearly. He was also

completely relaxed with discussing many of the more challenging and potentially embarrassing symptoms menopausal women may experience and easily instilled confidence that there is help and support available.

He says, “many people see menopause as an incident, when it is really a transition from one stage to another stage. It is, however, a very big process in a woman’s life and awareness of what women are experiencing is really lacking in our community.”

If women have more information and understanding about the menopausal transition, they can be better prepared. Whilst the symptoms a woman experiences may be uncomfortable and at times baffling, at least she will understand what is causing them. As they say, knowledge is empowerment and enlightenment can be liberating.

Here is the conversation with Dr Payam Nikpoor.

CAN YOU DESCRIBE THE IMPACT OF MENOPAUSE ON BLADDER AND BOWEL CONTROL?

With perimenopause we start to see changes in hormone levels, mainly oestrogen. For many women, the onset of night sweats and hot flushes can be very abrupt, but bladder and bowel symptoms can develop very slowly, so this is not usually a sudden change. Many women may also find their hot flushes and night sweats so overwhelming to deal with they may ignore other less bothersome symptoms. Once these settle down, some women will notice their bladder and bowel function is affected.

Let’s look at the impact of menopause on the female bladder. The genital tract, the vagina, vulva, and surrounding area, share embryonic origin (that is

when a baby is growing in the mother’s womb) with the lower urinary tract, that is the urethra and part of the bladder. Oestrogen receptors are present here, so whenever you see change in the genital system you can also see changes in the lower urinary tract. What happens for women is that they go from oestrogen abundance to significant deficiency and with that there is also a reduction in collagen and hyaluronic acid in the tissues. All these changes lead to differences in the connective tissue, which becomes thinner and loses its consistency. The term vulvovaginal atrophy was previously used to reflect these changes in the vulva and vagina during menopause. However, in 2014, the North American Menopause Society together with the International Society for the Study of Women’s Sexual Health,

Dr Payam Nikpoor, Urogynaecologist MD, FRANZCOG, CU

changed this to the genitourinary syndrome of menopause (GSM) which explains much more of what is really going on.

WHAT ARE THE PHYSIOLOGICAL REASONS A MENOPAUSAL WOMAN MAY EXPERIENCE OVERACTIVE BLADDER AND/OR URGE INCONTINENCE?

It is common for women to experience vaginal dryness, pain, lack of sexual arousal and satisfaction and urinary symptoms such as urgency, discomfort and urge incontinence. Let’s flashback to 20 or 30 years earlier when a woman gives birth. Normally, there is some degree of trauma to the pelvic floor, but the woman was younger, her pelvic floor muscles stronger then and more responsive to pelvic floor exercises, so compensatory mechanisms kick in and she may have no further trouble.

However, when she reaches menopause, the lack of oestrogen in the pelvic floor muscles, along with the changes in connective tissue and pelvic floor muscle trauma can lead to prolapses (dropping or bulging) of the uterus, bladder and bowel, which in turn can cause incontinence. If she has urinary symptoms and vaginal dryness, she may not act on these whilst she is dealing with bigger issues such as hot flushes, night sweats and mood symptoms.

A woman’s sexual function can also be affected quite significantly. Women can report sexual dysfunction from lack of lubrication and dryness. They may also report bleeding and pain with intercourse, which can last for several hours afterwards. It is not surprising that if your desire and arousal is affected, this will also affect your self-confidence and further reduce desire. Menopausal women also frequently present with urinary tract infections (UTIs) which can be debilitating.

WHAT DO YOU USUALLY RECOMMEND AS THE FIRST LINE OF TREATMENT?

I always say seek advice from the right medical professional and treatment usually involves a stepby-step approach. The starting point is lifestyle modification, encouraging people to adhere to an active and healthy lifestyle. I regularly refer my patients to the Continence Foundation’s website to access the guide on Healthy Habits for Bladder and Bowel.

As well as this we need to look at reducing smoking and alcohol consumption, ensure regular exercise, weight management, fluid control and dietary balance with adequate fibre. There are great resources available for free on the Australian Menopause Society website. If this conservative approach doesn’t help then it’s very important to see a GP with a particular interest in women’s health, such as the Jean Hailes for Women's Health practitioners.

The next step may be the restoration of oestrogen receptors with supplemental vaginal oestrogen. This has good effects on the genitourinary symptoms of menopause. I also refer all women to a pelvic floor physiotherapist and in some cases a sex therapist.

So, to summarise, the first line of treatment is the conservative one, addressing diet and lifestyle factors, then potentially vaginal oestrogen, and pelvic floor physiotherapy as a long-term investment for women in this age group. Naturally, if there are more significant issues such as recurrent UTIs, the presence of a mass or tumour, or history of cancer, they may need referral to a specialist.

Bowel control problems at menopause may be caused by pelvic floor injuries sustained at childbirth that can remain dormant. As time goes on, menopause comes along with the weakening

WHY IS IT THAT SOME WOMEN WHO HAVE HAD BIRTH INJURIES SUCH AS ANAL SPHINCTER DAMAGE DON’T EXPERIENCE BOWEL CONTROL PROBLEMS UNTIL THE ONSET OF MENOPAUSE?

of the pelvic floor and the connective tissue changes which may contribute to bowel control issues. Along with all these processes, we also have ageing so our capacity to regenerate tissue and the capacity of our muscles is reduced. This is where the role of physiotherapy comes in to help strengthen the pelvic floor. If there are significant issues or no response to conservative therapy, a referral to a specialist is required.

WHAT ARE SOME OF THE OTHER COMMON CONDITIONS YOU SEE IN WOMEN WHO HAVE POOR BLADDER AND/OR BOWEL CONTROL?

Pelvic organ prolapse (POP) is not uncommon. This is where there may be a bulge or lump and a feeling of heaviness in the vagina and pelvic area. In more severe cases there may be a protrusion or lump coming out of the vagina.

If not well managed, other conditions may worsen the symptoms. These include uncontrolled diabetes, a chronic cough and chronic constipation; repeated straining can contribute to POP, hernia formation and haemorrhoids. We also need to consider the very real current pattern of obesity which plays a role in prolapse and urinary incontinence as well as putting greater pressure on the pelvic floor. There is evidence that just 10% weight loss can lead to significant improvement in urge and stress urinary incontinence.

FINALLY, TELL ME A LITTLE ABOUT YOURSELF

I am a urogynaecologist and pelvic reconstruction surgeon. I have been with Jean Hailes since 2019 and it has been a great honour to be a part of this organisation. I work mainly in the Clayton medical centre as their urogynaecologist and at pelvic floor and perineal clinics in Dandenong hospital. In the perineal clinic we see women who’ve experienced anal sphincter injury during childbirth. I work with a great team of pelvic floor physiotherapists, and I do rely on their skills. “Without physios, I’m like a surgeon without arms.”

HOW DID YOU BECOME INTERESTED IN GYNAECOLOGY AND UROGYNAECOLOGY?

When I was a junior doctor, I had the opportunity to work with some senior obstetricians and gynaecologists. They became a true inspiration to me and set some standards in my career. In amongst the gynaecological conditions, pelvic floor problems are the ones that women may not come forth with. There is a stigma and “suffer in silence” pattern with these symptoms. I have a keen interest in this field and would like to help women with these problems. What I would like to achieve in my career, is to “inform and educate” women on these matters and to let them know there is help available and you are not alone.

SOPHIE 'S * STORY

SACRAL NEUROMODULATION CHANGED MY LIFE

By Vicki Patton, Clinical Services Lead, Continence Foundation of Australia

Sophie is a 32-year-old woman who has three children. During the birth of her first child, she had a difficult time, experiencing a long labour and having to push for over two hours. She was exhausted and eventually the obstetrician had to use forceps to help deliver the baby. Her baby was big, weighing in at 4kg, but was otherwise healthy. After the birth Sophie experienced some bowel accidents for about six weeks. She just couldn’t hold on for longer than a minute and the stool just came out. She was too embarrassed to mention this to anyone, so she just stayed close to home until she had opened her bowels for the day.

After the birth of her third child Sophie's bowel accidents became more frequent and the bowel incontinence began to rule her life. She was finding it difficult to get her older child to school in the morning and was suffering with increasing anxiety. Sophie declined invitations to take her younger children to the park as there were no toilets nearby. She was worried when invited out for a meal in case it triggered her bowel to work. Her husband knew that Sophie was having some trouble, but she didn’t tell him the full extent of her problems.

Eventually Sophie mentioned it to her GP, who sent her to a pelvic floor physiotherapist for some exercise training. This definitely helped her bladder leakage but did not help her bowel problem. The physiotherapist did openly chat with Sophie about her bowel issues, and it was the first time she felt she had someone to talk to about this embarrassing problem. What Sophie found out was that this is unfortunately a common problem and may have happened because of the difficult delivery of her first child. The condition was called faecal incontinence and her needing to rush to the toilet to open her bowel was called urgency.

The physiotherapist gave Sophie some ideas about establishing a regular bowel pattern, avoiding certain foods that may act as a laxative and discussed the importance of taking soluble fibre to help bulk up the stool. She also recommended Sophie speak to her GP about seeing a colorectal

She was too embarrassed to mention this to anyone, so she just stayed close to home until she had opened her bowels for the day.

doctor as there are a lot of treatments available for this type of bowel incontinence. Sophie was very nervous about seeing the colorectal doctor as she didn’t really know how to tell them what was happening. However, during the consultation, the doctor was very kind and seemed to know exactly what she was experiencing. Sophie was so overwhelmed with the relief that she would finally get help she couldn’t hold back her tears.

The doctor asked her to see the bowel nurses and undergo a bowel management programme and have some testing on the bowel to check the nerves and muscles in the anal area. The tests were called anorectal physiology and they showed that she had a problem with the nerves. The bowel programme helped a little and it made Sophie feel a lot better as she knew she wasn’t alone, and this was a common problem. She was still very embarrassed and didn’t tell her friends about what had been happening. She did tell her husband and her mother, and this allowed her to have a little more support at home.

After completing the bowel programme Sophie went back to the colorectal doctor. Although things had improved, she was still having bowel accidents. The doctor suggested that she was a good candidate for a sacral neuromodulation. The doctor explained that this is like a small pacemaker that is implanted under the skin just above the buttock and it resets the nerves to the bowel and prevents the bowel from dumping the stool into the rectum. It restores the normal nerve function.

The sacral neuromodulation is done in two stages. The first is a test run to see if the treatment will work. This is a day procedure where a small wire is inserted

into the back and connected to a tiny stimulator that is worn on a belt for about two weeks. During this time Sophie kept a bowel diary to see if it was helpful for her bowel control. She was amazed at the difference. She was able to delay going to the toilet and had control of her bowel for the first time in years. It was life changing for her. When Sophie went back to her colorectal doctor, she was very excited to report that it had worked so well.

Sophie was booked in a few weeks later for a second day surgery procedure. This time it was to have the permanent sacral neuromodulator inserted just under her skin. This is all internal with no external wires, not that different from a heart pacemaker except it is implanted just above the bottom cheek.

Sophie sees the nurse for programming her neuromodulator and a check-up once per year. The neuromodulator has a battery life of approximately seven years depending on what setting it is on. There are even rechargeable ones on the market now that will never need to be changed. The only limitation is that when she travels by aeroplane, she needs to say she has a pacemaker. She never tells the security people why she has it as there is

no need to and just goes through the side gate at screening. The model Sophie has is also MRI safe in case she ever needs to have that type of scan.

Sophie says it has changed her life and allows her to follow the active lifestyle that comes with having young children. She now has her confidence back and is always happy to discuss the procedure with other patients considering it.

Her advice is “at least have the test done to see if it will work as the potential benefit is amazing!"

Sacral neuromodulation only works for particular types of faecal incontinence and is not suitable for everyone. It is best to discuss this with your doctor to see if this may be a treatment option for you.

*Name has been changed to protect privacy.

Artwork by Tam BowerJean Hailes is supported by funding from the Australian Government.