The Dr Louise Newson Podcast - 023 - Menopause & the Pelvic Floor - Nicola Mulkeen & Dr Louise Newson

Episode Date: November 12, 2019

In this podcast, Dr Newson is speaking with Nicola Mulkeen, a very experienced and knowledgeable pelvic floor physiotherapist. Together they discuss what exactly the pelvic floor muscles are and what they do in our bodies. Nicola talks about the importance of regular pelvic floor exercises and how to perform them. Dr Newson also asks Nicola about different types of urinary incontinence and how women experiencing symptoms should be receiving the right help and treatment. Find out more about Nicola here: https://www.newsonhealth.co.uk/holistic-therapies/physiotherapy Nicola Mulkeen's Three Take Home Tips for Pelvic Floor Health: Don't suffer in silence - get a referral from your GP if you have any concerns. Prevention is better than reacting to symptoms once they occur, so it's always a good time to start thinking about your pelvic floor health. Don't be embarrassed to talk about bladder and bowel problems or sexual health.

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsom, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today I've got Nicola Malkin, who's a local pelvic floor physiotherapist, who we're really fortunate, works with us in my Menopause and Well-Being Clinic in Stratford-upon-Avon, as well as working locally and the NHS. So hi, Nicola. Hi, Leruiz. So pelvic floor physiotherapist, I'm not sure many people will know what that is. So before we get started, can you just explain what that means? Yeah, so a pelvic floor physiotherapist is someone that deals with any sort of symptoms,

problems related usually to the pelvic area. So it could be related to urinary incontinence, symptoms of pelvic organ prolapse, which we can talk about a little bit more, any difficulties following childbirth, for example, tears or traumatic deliveries. So it's all about really addressing the pelvic floor muscles, which are the muscles that sit in the basin of the pelvis. And those muscles are there to help keep women continent from a bladder and a bowel point of view. And they're also there to enhance sexual responses as well. So, yeah, a lot of people don't really appreciate that we've even got a pelvic floor. So, yeah, because pelvic floor sounds a bit weird, doesn't it?

It doesn't sound like it should be in a part of our anatomy. And it's not just one muscle, is it? No, I mean, it's a group of muscles. We have a superficial layer of pelvic floor. We also have deep muscles. And actually, the expanse is much wider than I think a lot of people understand. So when I first speak to patients, I always kind of ask them if they know what the pelvic floor muscles are and very few have a very good grasp of that so I would get a pelvic model out and I would

demonstrate exactly where the pelvic floor muscles run from so the front of the pelvis the pubic bone and they run all the way around and attach on the coxics at the sort of the very end of the spine and it's a very broad large area of muscles so when you start to look at the anatomy and you explain that to patients and just how that can be impacted. I think that can be quite a light bulb moment. It's huge area, isn't it? Yeah, I mean, I think a lot of people think it's just maybe a little bit of muscle around the erythra, so when we wee it gets affected or even around the vagina for childbirth. But it's more than that.

Oh, definitely. Yeah. And even when we talk about bowel problems, so when I speak to patients about the fact that the pelvic floor has an influence on blood and bowel control, that can sometimes come as a surprise for people. So I think, and because of where the anatomy is, it's an area that people don't often like to ask a lot of questions about, or they feel embarrassed to ask questions about it, or, you know, they've had a lack of education. So I know in schools, the curriculum is really quite limited. I know that's improving, that topics like the menopause aren't not talked about. And I know that, you know, local MPs have sort of balleted to try and get that on the curriculum. and I know that will be happening, so that's fantastic. So if we can impart that kind of knowledge to youngsters and teenagers,

just to get facts from fiction. So a lot of patients I speak to have this idea of what's right and wrong and, oh, well, I've had babies, it's okay to leak because that's, and that's just not right. No, and I think, I mean, you're right. We'll talk about it more detail, but you now see, you know, if you go and buy sanitary products, they've got range and range of 10 ladies and all these other products, which obviously are good. People don't want to be wetting their pants

and dribbling down their legs, but actually we want to take a step back and stop it even happening. And I think you're right. Lots of people think it's normal because it's so common and because we don't talk about it. But we are only really going to focus on women,

but men have pelvic floor, don't they? And I think a lot of men don't realize that. They always think it's their female problems. Yeah, and I do see a number of male patients as well. And, yeah, like you say, often when you mention to them the pelvic floor, they kind of say, oh, that's the women's issue. That's not something I need to be worried about. And so actually, it can be quite rewarding, talking to men about these kind of problems.

Because, you know, for men, it can be even more challenging sometimes to come forward with those kind of symptoms or concerns. So, yeah, it's as important for women as it is for men. So, yeah, I think we've just got to talk about it. Yeah, so clearly, obviously, all I do is live and breathe and talk about the menopause. But even going back earlier, so I've got my two oldest children of teenagers, and one of them sometimes if she's laughing too hard or she's she's on the trampoline she's oh god I got to go to the toilet and she runs and I keep saying because you've got to start doing your pelvic floor exercises and she is a bit in tune but she still knows my friends

are like that mummy yeah and I think when I mean when I've done Pilates training which is slightly aside but one of the instructors worked with ballet dancers and elite gymnasts and he sort of spoke about how they normalized leaking in part of you know their ballet training and their sort of their advanced gymnastic training, well, of course I leak when I do rebound work. And it's like, well, no, you shouldn't. It's not normal, is it? Again, I think there's a lack of education around teaching

or, yeah, they don't know how to do a pelvic floor contraction correctly or in some cases they do it incorrectly, which can actually be... Exactly. So it talks through, I know it's very hard because we're talking through microphones. But firstly, do you think all women and probably men should, do pelvic floor exercises regularly. Without a doubt. And whenever I see patients for the first time, I sort of emphasise the importance of these exercises, not just being for the duration of the time that they're going to see me, but this is exercises for life. And that can be a little bit daunting,

but a little bit like brushing your teeth or, you know, cleaning your hair, etc. It just needs to become part of an everyday routine. And should we mean starting as a teenager? I think we should, yeah, definitely. You know, as young as, you know, as, girls and boys can sort of understand and appreciate where those muscles are and what they do. I think it would be valuable for us or for people with knowledge to go into sort of gymnastic classes or other sports arenas and as well as talking about stretching and, you know, strengthening. I think we need to address the pelvic floor in this group of, you know, because teenagers and young people like to exceed at athletics and different vocations. So I think if they want to exceed, they need to be

looking after not just their leg and arm muscles, they need to look after their pelvic floor as well. So, yeah. So talk us through then briefly. What do you do then if you want to do a pelvic floor exercise? Yeah, so we tend to not advise ladies or men to do them sitting on the toilet because historically we were sort of advised that if you tried to stop your urine mid-flow, that was your pelvic floor contracting, which it is.

But we now know that actually to interrupt the bladder flow during a, avoid a wee is not advisable. So I would sort of say, well, that's kind of how it would feel. But I would get someone to sit comfortably both of their feet on the floor. And first of all, I'd just get them to connect with their breathing. So because actually a lot of the time people don't breathe properly, which might sound bizarre. But if you can't breathe properly, then that can also be a problem with the pelvic floor muscles engaging correctly.

So I might say to my patient, just take another couple of nice, deep breaths. into your tummy and then I shall say to them as you take a breath out I'm going to get you to imagine that you're trying to stop some wind around your back passage and then you're going to imagine that you're pulling from the back round the front as though you're trying to stop that way so you're squeezing and you're lifting as you go almost like you're kind of drawing a zip from your anus from the back passage round the front towards your urethra and it can take a little bit of getting used to. And I always say, don't be too sort of alarmed if you can't get it straight away. Some people can't really feel a lot that's going on down there. And certainly from a physio

point of view, we can sort of help if the sensation isn't great or if it feels tricky to do the activation. We can talk about strategies in terms of whether we use a stimulator to try and get them to connect with their pelvic floor muscles, or there's lots of different biofeedback devices, which again we can use visual and auditory feedback to encourage the lady or the gent to do their pelvic floor contraction correctly. As a physio, generally I would do an internal examination with my patients to sort of deter whether they are doing that contraction correctly. And again, I know that could be a little bit frightening for somebody, but you know what, if you've been struggling with symptoms for years and years... Desperate for help.

Yeah, I think for the sake of a couple of minutes to just assess where those muscles are working properly And actually most people are really grateful to have that input and to get that feedback from somebody because it could be the first time in all their life that they've actually known whether they're doing something correctly. So often if ladies have babies, they're given leaflets to say, do your pelvic floor exercises. But no one really knows how to do those. So it's just about giving them the knowledge. How many times should we be doing that? Yeah, I tend to suggest to most of my patients that we should be looking to do our exercises three to four times a day.

in the literature there's lots of different sort of recipes if you like i tend to say to my patients we want to build up to be able to hold for the count of 10 seconds and then to be able to do that 10 times and we also work on what we call some fast snatches which is where we do a quick rapid squeeze and then we release fully and the reason we do that is because the pelvic floor has two different types of muscles so we have slow twitch muscle fibers and we have fast twitch muscle fibres. So the muscle types work in slightly different way. So for example, if you have stress incontinence, which is incontinence when we exercise, when we laugh, etc., then we need to have muscles that can react quickly. So that's why I would get the ladies to practice the quick ones.

And then the slow holding contraction is designed for sort of endurance and stamina because we need to have a baseline of tone throughout the day to support. Because the pelvic floor, essentially is there to support all our internal organs. So if there's weakness there, then obviously that will cause potential problems. Yes. So that's really interesting, isn't it? Because you talk about incontinence. And I don't ask it anymore, but I used to ask when I was a junior doctor,

have you had any problems with incontinence? Firstly, always people think that's bowel. So they think, have I pooed myself? No, I'm fine. And then you say no, with your urine. And they say, no. But when I say, do you have a leak when you cough or sneeze, or do you have to rush to the toilet?

Oh yeah, all the time. Yeah. But they don't think that incontinence, because a lot of people think that's if you really were yourself completely. Yeah. Whereas actually even a little dribble is still a type of incontinence. I think any, any leak, no matter what's provoking, is not acceptable. And as lovely as it is to have more advertising around bladder and bowel problems,

a large percentage of the sort of advertising is done through tenor and pads and protection. And it makes it almost acceptable then. Yeah. Yeah, and I think we need to move away from that culture of just accepting and padding up to actually, we'll know there can be solutions out there. And certainly before we consider sort of major surgical intervention, I think, you know, all women should probably go down a conservative route first. So that would mean seeing a physiotherapist who can assess their pelvic floor, you know, work on the pelvic floor for a minimum of six months just like you would any sort of gym regime just to try and see if through doing conservative treatment initially. whether that's going to be successful alone. Exactly.

And, you know, having big surgery, particularly in your pelvic region, you know, it's quite distressing. And there's no guarantees necessarily. You can have surgery for pelvic organ prolapse, but there's always a risk of recurrence or for different areas to sort of come down. So, yeah, if you were going to have knee surgery,

you would do exercises to strengthen your knee prior to that operation. So it just makes sense to me that you, Absolutely. And I think if people then did have surgery but they've got good pelvic floor, they're going to recover better, aren't they? They're going to recover better, exactly, and they're going to get better long-term results from the surgery in the first place. So if a woman listening to this, or has got a friend who's listening to this, is struggling

with, I've got friends to say, oh, no, I can't run and I'm always at your knees, no, because I'll just leave. If you've got friends like that, then they should seek help from their GP, but they should really be asked to be referred to a pelvic floor physiotherapist. Yeah, without a doubt. And I mean, time and time again, when I assess ladies for the first time, I hear, oh, when I ask them how long have they had symptoms for, it's often not just a few months, it's often years. And, you know, it's taken them a long while to pluck up the courage to go and get a referral. Or they say to me, oh, I just thought, you know, if I ignored it, it might go away, or I just thought, presumed in time, it might get better. But when certain situations like the menopause hit, then certain things can become exacerbated.

so they might put up with things on a certain even keel and then they hit the perimenopause or years and then things start to worsen in lots of different ways and that might be when they start to sort of seek some help and lots of people don't see that so as I'm sure you know people that listening that the perimenopause is that time before periods stop so often people find their periods change in nature or frequency and they get menopause or symptoms so they can get flushes sweats, but also symptoms such as reduced mood, low motivation, muscle joint and joint pains, resting headaches, but they can also get urinary symptoms and vaginal dryness. And this is because we have estrogen receptors all over our bodies, but we have them in our pelvic floor,

don't we? And in our vagina and in parts of our bladder as well. And so I routinely, when people come and see me with menopausal symptoms or perimenopals or symptoms, I'll always ask about their bladder and they all look and say well why are you asking me that and they don't realize that it's related they think it's an age thing as opposed to a hormone problem so and i will always try and educate women you know in the perimenopausal years so ladies you know in the early 40s that even from our 30s our estrogen levels are depleting and so in actual fact if we can implement strategies to support our estrogen through sort of natural resource be that nutrition, be it through exercise, if we can do the best to support our system,

our adrenal function when we're in our 30s, then when we do hit the menopause in our 40s and 50s, we're going to be in a better position. But sometimes people can be a little bit surprised that, you know, well, I'm only in my early 40s and we're starting to talk about the menopause. But I think, you know, one in 100 women under the age of 40, you have an early menopause. So we don't know when it's going to hit us. And I always think it's a bit like, Before women get pregnant, it's great when they're really fit really well before they actually conceive. And it's no different with the perimenopause and menopause. So we've talked about treatment as in doing the exercises.

But also, if women's perimenopausal or menopausal, often giving the hormones back can make a big difference. And as you know, estrogen is really important. And if they're getting systemic symptoms, we'll often consider HRT. And even testosterone, which is a male hormone, but we produce it as well, we have receptors for testosterone, don't we, in our pelvic floor and bladders. So a lot of people find the combination can make a difference. But for those women who can't take HRT or don't want HRT, we can still give local estrogen, can't we? Which can make quite a difference. Yeah, definitely.

And in part of the examination process, when I'm assessing the pelvic floor, I'll also be looking at the health of the vaginal and the vulva. tissue and you know it's not unusual and to find that there is some degree of vaginal atrophy which would indicate that the estrogen levels are depleting and that actually local estrogen may be of benefit and you know we're talking about a little tablet a little pestry that they can insert at night time so it's relatively straightforward procedure i usually say to my patients that this is something that we're going to need to do over a certain period of time to to try and sort of replenish the lost estrogen but you know, as well as local estrogen, we can think of local moisturisers and lubricants as well.

So if ladies are really sort of not sure about estrogen for whatever reason, then we can always look at some other sort of natural products that can be useful. So there's loads available on the market. There are, but there's some really horrible ones as well, aren't there? So you just need to be very careful that the products you're going to use are organic, that the ingredients are natural. And certainly within clinic here, we've got samples. So, for example, one of the brands is yes, you produce kind of oil or water-based lubricants. So sometimes they can work quite nicely in conjunction with local estrogen. So, for example, if intercourse is an issue, which again, not all women are very forthcoming

in wanting to discuss, but as part of the routine assessment process, I will always ask about sexual issues or how intercourse is for a lady. And, you know, if a lady says, well, we're not doing it for X, XYZ, or it's uncomfortable, or it's painful, then obviously I will sort of talk about what strategies we can do to help that. I don't think it's fair just to expect to get to a certain age and then not be in a fulfilling sexual relationship because you can't because of pain or discomfort. So those are things that we can definitely help with. Yeah, and it often does go hand in hand, doesn't it?

And it's amazing the number of people I see who have just stopped having sex. And sometimes it's because of reduced libido or just the way they feel because of the menopause. but often women tell me because it's so painful. And the lady told me a couple of years ago now that having sexual intercourse with her husband was like having a red hot poker shudged inside her. And I said, did you not do anything? Or she said, no, he was so desperate for sex.

I knew it would be over soon. But that's not a way to live, is it? No. And again, because of a little bit of taboo around talking about these kind of topics, I think women will either just put up. Put up and shut up really. Yeah, exactly. I mean, I see it with newly postpartum, you know,

you know, postnatal ladies as well, having difficulties. You know, they want to just appear like they're managing okay. But, yeah, I think if you've got sexual difficulties, don't just suffer in silence, get, you know, get some help. Yeah, totally. I mean, I've talked at length with Diane Porterfield and another podcast and also Jane Lewis, who you know, who wrote them amazing book, My Menopals or Bagina about different treatments. And you say, yes, is a really good, they do, a lubricant as well as moisturiser. Also, we have silk and regale here in the clinic. but there are some of the sort of scented products that are heavily promoted and marketed in some chemists and online,

but they can often cause a lot of smarting and irritation. And I think, yeah, some of these vaginal sort of doches or washes that are sometimes advertised, I'm just a little bit cautious about those and I just say to any of my patients, you know, read the bottles, check the ingredients because, you know, it's a sensitive area and we all want to be looking after it. And I think because they're marketed so well, we're all into this. era of trying, you know, it's all sucked into nice products and nice packaging, but often say to patients, we don't wash our mouths out with soap. So why do we need to wash our vaginas out? And this idea that things have to smell a certain way or, you know, because

of the natural area anatomy-wise, you know, there is a distinct scent, but we shouldn't necessarily be covering it over or it's how our bodies are. It's natural. It's, you know, that's the way it should be. Yeah. And I think there are some people who get infections clearly that need to be treated. But we see a lot of women who incorrectly think they've got thrush and they self-medicate. And because the pH changes with the low estrogen levels, like you say, odour can sometimes smell or secretions. And some people actually, I saw a lady yesterday in my clinic who, when I asked if she had

any vaginal dryness, she said, no, it's the other way. It's very, I've got a lot of secretions. But actually, she still had some dryness and reduced estrogen. But it's just the way that the body responds to that. It can cause mixed messages sometimes, not it. Yeah, definitely. I think certainly for me, when I was working as a GP, it's really busy and you've got 10 minute appointments and often people come in with something and then towards the end,

they'll say, oh, doctor, by the way, I've got a bit of incontinence or some leakage, or I'm examining them for something else and see that they're all padded up and I'm saying, what are you doing? And so actually then it can be quite difficult to have the time, whereas to refer to someone like yourself, who's a complete expert in pelvic floor physio, who can take a really detailed history, often give people diaries, don't you to fill out, to examine, like you say, in a very sensitive expert way is really important. So I think if women feel embarrassed, firstly they shouldn't, because we're not embarrassed about any of this, but also if they've been sort of fobbed off

or dismissed as it's normal, then they should really go back, shouldn't they, and ask to be referred to. Definitely. Yeah, definitely. And, and, you know, and, you're not referred. Yeah, definitely. And. And, as I say, time and time again, I hear if only I'd seen you sooner. I didn't realize, you know, that someone was around that could help me. So I think, you know, if we can educate GPs or other healthcare professionals that we're here and, you know, we're very much advocates of promoting looking after the pelvic floor. I mean, it would be great to be able to serve every woman that walks the earth. But I think through social media and research and things, I think it's becoming

more prevalent and there's more knowledge coming to the forefront, which is brilliant. But I think there's still more that we can still do to help women. So it's a real honour and privilege having you working here in the clinic, seeing some of our patients. So thank you. So just before we end, it would be really useful if you don't mind, just giving us three take-home tips, what women could do or think about to have listened to the podcast. Yeah, I think the first probably is don't suffer in silence. If you have any concerns whatsoever, get to your GP, get a referral to see a pelvic floor physiotherapist.

So preventing problems from occurring is much better than reacting to them once they occur. And don't be embarrassed to talk about bladder bowel or sexual issues. They're a normal part of life and we need to just sort of get over the taboo and just talk about them and get help. Absolutely. Improve our quality of life for these patients. I think that last one is totally pertinent. You know, there's a menopause taboo, but there's even more of a taboo with urinary symptoms. And you've certainly written a lovely article on the website, which you can easily find on my website about ure symptoms and pelvic floor.

And I think the more it's talked about, the more it's normalized, and the more hopefully women can get help. So thank you ever so much for coming to talk today. That's all right. Thank you. For more information about the menopause, please visit our website, W. www.menopausedoctor.com.uk