The Food Medic - S4 E3 - Periods 101 and the Menopause

Episode Date: May 22, 2020

On this episode, Dr Hazel is joined by GP, Dr Philippa Kaye. On this highly requested episode, they cover everything to do with periods - what is normal, what is abnormal, what is irregular, how heavy is too heavy - and also the perimenopause and menopause. Let us know if you loved it by leaving a review and a 5 star rating - it really does help. Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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exclusions, and terms apply. Instacart, groceries that over-deliver. Hello, and a very big welcome back to the Food Medic Podcast. I'm your host, as always, Dr. Hazel, here to explore some of the most relevant and hot topics in medicine, nutrition, and healthcare. And today, I'm joined joined by GP Dr. Philippa Kay. Philippa has written multiple books on women and children's health. Her most recent book was published in February 2020 and reached the top 10 on Amazon, titled The M Word, everything you need to know about the menopause. Now many of you guys have been asking for a podcast covering everything to do with periods. And so on this episode, we will be discussing just that. What is normal? What is

abnormal? What is irregular? And also about the perimenopause and the menopause and urinary incontinence. This is a jam-packed episode, but I know you're going to love it. So make sure to listen right through to the end. First of all Philippa thank you so much for coming in today and giving us your time. Nice to see you. Yes I've been looking forward to this conversation. So you are a trained GP but you have a special interest in women's health and I'm interested to know what drew you to this initially. So I have a particular interest in women, kids and sexual health and extra qualifications that go with those. And when you're a GP and you go around the hospital

and you do different jobs and different specialities, those were the jobs where I thought I could be happy here, I could live here and I would be interested for the rest of my life and then I couldn't choose. And the only way that you can do that is to be a GP and then you can special specialize sort of within that and so I do general general practice but then I can also do all the women kids and social health as well yeah so it's just something that was always an interest always an interest if I wasn't

going to be a GP I wanted to do developmental pediatrics which is the study of babies and children's development. But that didn't fit in with life and all the other things that I wanted then to do. And in general practice, you have it all. And what's really special about general practice is that long term relationship that you really build with patients, you know who they are, and they know you, and you see the outcomes of what you do. And that's really different hospital medicine where you sort of have a really brief intervention, and then you move on. Yeah, that's very true. So we're going to talk about your book, The M Word, in a moment. And that's all things to do with the menopause. But first of all,

let's chat about periods. Now, this is a topic that so many women come to me and they just have lots of questions. What is normal? What what is irregular what is too heavy and I just think you're the best person to kind of hash all of this out with I know that it's a huge topic and we probably should be covering this in a separate episode but let's see where we get on so what's normal is what's normal for you and that could be different between you and your sister and your best friend but it's what's normal for you. And what's abnormal is also what is a change from what is your normal or what you can't manage. And that can be very different between different people. So you're all taught in secondary school that your period comes

every 28 days. But regular sort of means between every 21 days and 35 days. So three to five weeks in your menstrual cycle. And then women will bleed anything between three and seven, eight days. If you're bleeding more than 10 days, I want to know about it. And then during the course of your period, you tend to lose only about 80 mils of blood, which doesn't seem that much when you think about sort of what collects in a tampon or a sanitary towel, but 80 mils is not a lot.

And we used to ask questions about how heavy it was by how often you changed your pad, or did you leak, or did you pass clots, or did you sort of leak at night and actually how often people change their pads is really different depending on sort of their work environment or their own ideas and so what we ask now is are you managing because if you think it's too heavy and you're not managing then it's too heavy if it's so painful that you can't go to school that you can't go to work then you're not managing and that's when we need to know about it if you bleed in between your periods if you bleed after sex if you bleed after the menopause then those are all things that we definitely want to know about but whatever it is you can still come to us and then we have always have lots of options. And I think that people think, oh, I'm a woman, I'm supposed to have periods, I'm supposed to put up with it. And

that's not true. Yeah, I think that's really important to point out, because we all know that when we are going through puberty, we're often advised, you know, you're going to have cramps, it's going to be painful, but don't worry, you know, you'll get through it. And it's just normal, it's normal part of being a woman. But sometimes the pain is out of proportion to what it should be. And something which we call medically dysmenorrhea. Let's chat about that and some of the causes and how do we know when it's abnormal? Like you said, I know you mentioned all of the things before. So dysmenorrhea means painful periods. And that's also associated with another word which we use, which is menorrhagia, which is abnormallyally heavy bleeding. Now I've had a patient who couldn't leave the bathroom for two

days every month because her periods were so heavy and painful and she thought that that was normal. People who vomit every month, who the pain starts before the period, the pain travels into their back, it travels down their legs and they're just not able to manage with a simple paracetamol. Now for some people that's what we would call primary dysmenorrhea, they've always had it and for other people it's secondary, it's secondary to something, be that fibroids which are benign growths in the womb that can make periods heavier and more painful or other conditions such as endometriosis where there are patches of essentially womb lining tissue in other places where it should

not be, be that the ovaries or somewhere else in the pelvis. Those tend to make the periods more heavy. But generally, if you've always had heavy periods and you go to your GP, they're not going to start off with an ultrasound. We're going to start off with some treatment to make you feel better because this is so common. And we're going to say definitely, you know, you start with paracetamol, ibuprofen if you can take those things. Importantly, if you get pre-period pain, so I know I'm coming on because my breasts are swollen and I'm grumpy, but also now I'm getting cramps even though I'm not bleeding, start taking your painkillers at that point, at the pre-period point, because it's far easier for us to stay in control of pain than to have to get back on top of it so if you

wait until your pain racks up to really unbearable we're going to have to use far more medication than if we started taking the medication when the period pain was let's say three out of ten bad and then if that doesn't work then we have other medication we have one called tranexamic acid which works to stop the period being so heavy, and something called methanamic acid, which is in the same class of drugs as ibuprofen. And together, they don't work as one plus one equals two, they work what we call synergistically, one plus one equals four. So the two of them together work better than either of them alone, not only to decrease the amount of clots and the amount of bleeding, but also the amount of cramps that you have. And so those are only taken during the time of your period. And for some women, that's marvelous,

and that's more than enough. Other women will need to take something the whole month. So if, for example, we were to use a contraceptive pill, I could turn off your natural menstrual cycle, I could turn off ovulation. And therefore, your periods are going to be a lot lighter it's going to be a withdrawal bleed and actually you could take the pill back to back for a period of time and if you can't have the pill for example you have migraines and then we can give you a new version of what we used to call a mini pill and about half of people that will stop ovulation and if that doesn't work then we're going to step up okay so that we have hormone coils they actually use the tiniest amount of hormone of all the hormonal medication i can give you and you can have it even if you

haven't had a baby and by one year of using it 90 of women will have no bleeding at all so it's marvelous and it works for contraception as well and if that doesn't work then they go in and sometimes they sort of and they do an ablation procedure which is essentially where they try and burn out some of the room lining tissue but for generally for young people one of the things that we've already mentioned be that pain killing medicine anti-heavy bleeding medicine or a form of contraception is really effective and at what point will the gp consider maybe doing investigations for a secondary cause so for some other underlying cause so if you you're not managed with, for example, a contraception, then we would have a look. Or if we already thought something else was going on.

So let's say when we examined you, we thought that the pelvis felt very full and we were considering maybe there's fibroids, then we would go and have a look. But even if it was fibroids, the treatment initially would still be the same. So we're not going to subject somebody to an investigation unless it changes what we are going to do afterwards. But if what we're doing isn't working, then absolutely, we're going to go for an ultrasound first, because you can really see the female reproductive system really well, either through the vagina or through the tummy. And if that's not enough, then we can do other investigations. But something like endometriosis, really the gold standard of diagnosing it is through what we call a laparoscopy, which is keyhole surgery where the surgeon directly sees those patches of tissue.

And that can be really difficult because the size of the patches of tissue doesn't really correlate with symptoms. So you can have loads of endometriosis patches everywhere and actually have very few symptoms entirely. Or you can have one tiny patch that is causing real problems. But as the treatment initially is the same, we're going to go down the simple route first. Yeah, that makes sense. So kind of to summarize everything there, what you're saying is, yeah, it's a lot. But to ultimately know what's abnormal for you and know that it's okay to put your hand up and say do you know what i'm struggling and i need some help here the eve appeal which is the gynecological cancer um charity in the uk has a really good campaign

which is called know your normal because if you don't know your normal then you don't know what's abnormal so however you track your periods be it a little circle in your diary or you know an app on your phone it doesn't matter but you have to know what is right for you. This is what my discharge is like. This is what my period is like. This is what my pain is like. And therefore, when you deviate from that, you're able to say something is going on. And remember, your doctor is only trying to do their best job. They do not care whether or not you had a leg wax, whether or not you just went to the gym, whatever it is, we've seen and heard it before. Yeah, absolutely. Okay, so we talked about periods. Let's talk about the menopause and the perimenopause. Yeah, so we all

learned about the birds and the bees at school. And we learned what was going to happen to our bodies and changes in our bodies. And we learned where babies come from, and very importantly, where babies don't come from. But we weren't really taught about the menopause and the menopause is the end of the periods. So menarche is the medical word for the first period and menopause is the medical word for the last period and it is a diagnosis of retrospect. That means that I cannot tell that you've been through it

until you have not bled for one year. But you can have symptoms for a decade before and you can have symptoms for many, many and you can have symptoms for many many years afterwards so whether or not you have periods if you are struggling with symptoms then you go and see your doctor because we can help and treat whether or not you still have periods and those symptoms are the things that we all might know about the hot flushes and sweats because our mothers were hanging out the window having debates with our fathers about the thermostat but actually there's a whole load of other symptoms physically things

like joint pains headaches palpitations where you can feel your heart racing dry itchy skin loss of libido so loss of sex drive insomnia fatigue and then psychological symptoms depression low mood anxiety panic attacks what we call the menopausal brain fog which is difficulties with memory and concentration i have patients asking if they've got dementia. That's how bad the symptoms can be. And then there are aesthetic things. So you might notice a change of where you lay fat down, you might notice some hair loss on your head, but some hair growth in other places. And so if you add that all together, it's not a wonder that women are quite frankly look at that point in their lives with despair um but actually

it's a really good opportunity to take stock and for many women it's a chance to be free of the burdens perhaps of child care or the burdens of whatever else you have to do or even the burdens of your periods themselves so if you're struggling get help because we're going to live a third of our lives as women in a post-menopausal. And we don't want that third of our lives to be miserable. We want it to be well and healthy and happy. So if you are struggling, definitely you need to go and see a doctor. Yeah. Like you said, it's something that we don't ever address.

We, you know, brush over it at medical school. And it's something that there isn't a lot of support, or there is, but we don't talk about where that support is. And it's something that shouldn't't a lot of support or there is but we don't talk about where that support is and it's something that shouldn't really be a taboo it's very normal physiological process yeah and even women don't speak to other women about all of it so they might say oh i'm hot you know and grab a fan but they're not going to talk about the fact that they haven't wanted to have sex and the impact on their relationships they don't talk about the fact that 10 of women consider giving up work because of their symptoms and more women are in the workplace than have ever been before. And we need to look after them. And we need to look after each other. And we're really

kind to teenagers. They're grumpy, and they want to sleep all the time, you know, and we're really kind to them. And we say, oh, you're going through puberty. And you've got receptors for those hormones all over your body and in your brain. And that's why you you're having those symptoms we need to be equally kind to women going through the menopause yeah absolutely and i'm sure you get asked this all the time but there'll be women who approach me and they're like can i delay it or how do i know what age it's going to happen so look at your family history um so if your mom it's particularly accurate, but if your mum and your aunties and your grandma and everybody had a particularly late or a particularly early menopause,

it's possible that you're going to follow in those footsteps. The best thing that you can do though to delay your menopause is to stop smoking. So smokers on average go through the menopause two years earlier than people who don't smoke. There's a little bit of evidence that's not brilliant about omega-3 which is found in fish potentially having an effect but we're not really quite sure

and a piece of evidence that came out recently that said your menopause happens when you run out of eggs you're born with all your eggs that you're ever going to have and by the time you reach puberty about half of those have already been absorbed and then every month you lose one egg but about a thousand get absorbed into the. So you only really have enough for about 40 years worth. So if you do something that's going to mean that you ovulate less, so if you have lots of babies, if you breastfeed for a long period of time, you won't ovulate for nine months of pregnancy and potentially when you're breastfeeding. And because of that, there's beginning to be some evidence that maybe people who have children are more likely to have a slightly later menopause, but it's really only sort of slight within a year or so. The average age for the menopause in the UK is 51.

Okay. And let's just briefly touch on the kind of early menopause or premature menopause. So what is this definition and why might that happen? So this is really important because of the impact of the long-term estrogen deficiency state. And because after the menopause, your ovaries aren't working, they're not producing estrogen, progesterone or testosterone, and that's what produces your symptoms. A premature menopause is defined as going through the menopause below the age of 40. One in 100 women will go below the age of 40, one in a thousand below the age of 30 and one in 10,000 below the age of 20. I love a stat that is easy to remember. And there are lots of reasons why it happens. Sometimes your periods never start

and that can be a genetic condition or a hormone receptor condition. But if we're talking about a situation where your periods have started and then they stopped, sometimes we don't know what the answer is. Sometimes it's linked to other conditions, which are called autoimmune conditions, conditions where the body attacks itself, like type 1 diabetes or thyroid problems, and the body can attack the ovaries in the same way. And sometimes it's doctors that have done it to you if we remove your ovaries for example because of ovarian cancer or a twisted cyst then as soon as we remove your ovaries we're putting you into a surgical menopause straight away and sometimes we give medications that induce a medical menopause and there can be various reasons for that including hormonally driven cancers and other things so it's either something that your body is doing

and we might know the reason and we might not know the reason, but either way, we can't change what's happened or it's something that we have done to you essentially, but for a reason. And generally that reason is because, you know, it's a life-saving procedure essentially. What is important though, is that once that happens, you're already in this estrogen deficient state. And we know that when women have gone through the menopause, their risks of things like heart disease, dementia, and osteoporosis, which is thinning of the bones, go up significantly. The oestrogen is really protective. And that's why women don't have heart attacks in the same way that men have heart attacks. And so if you're in the oestrogen deficiency state 20 years earlier than we would otherwise expect, your risk is going

to go up significantly. And that is why anybody who has a premature menopause is encouraged to go on HRT. There are no risks at all of being on HRT until the age of 50, because you are simply replacing the hormones that would otherwise be there. So I know we're going to talk about it, but there are often concerns about the risks of HRT. really it's really important to remember there are no added risks with a premature menopause and so the headline is essentially this if you've started your periods and you've got into whatever your regular cycle is if your periods stop for more than six months you must go to the GP we're going to investigate that we're going to do some blood tests and I'm not saying you're definitely in the premature menopause there's lots of reasons why it could happen including medication and and lots of

conditions but we would need to investigate find out why and therefore decide what we do next yeah i think that final point's important for us to kind of reiterate that while um the premature menopause is one cause for women losing their periods they're becoming amenorrheic there are also lots of causes so if you're listening to this and maybe this applies to you don't just panic straight away go see your GP we're going to do lots of tests and figure out what's going on and importantly don't assume that because you haven't got a period you can't get pregnant so even if you've gone through the premature menopause actually one in 10 women will randomly ovulate again at some point and we don't know when that point is and so we would often actually use contraception as well as HRT or contraception

as HRT so whatever your cause of not having your periods is be that a weight related issue or a thyroid related issue um there is still a risk of pregnancy so don't assume one or the other okay so we you touched briefly on HRT and that's something I want to discuss next because you know open up any newspaper and almost HRT is popping up almost weekly in terms of the benefits the risks I know I'm asked by lots of women should I take it um some women swear by it say it's amazing keeps them youthful um and then there's also headlines saying, you know, it increases the risk of lots of conditions. So what are the risks and benefits and how can a woman weigh them up? So HRT is hormone replacement therapy, does what it says on the tin, we are literally replacing the hormones that you've lost. Generally, that's estrogen

and progesterone. And sometimes we add in a smidge of testosterone as well. Now, when HRT was invented in the late 20th century, it came, the drug name was brilliant. It was called Premarin from pregnant mare's urine. So literally, lady horse's urine. And it had the hormones in, and that's where we got it from. And women were started on it, and it was the panacea for all ills. And then a big study came out in about 2000 that said, hang on a second, there are risks here.

And I often get asked, why do doctors change their guidelines? Why do they change their minds? Why are you now saying it's safe when before we said it wasn't safe? And the answer is, is we change the guidelines according to the research. And as more and more research comes out

and we know more and more, we're better able to discuss those risks. So let's put them out there and go through them one by one. The first one and the big one that people always ask me about is breast cancer. If you have a womb, then you have to have estrogen and progesterone. If you do not have a womb, you've had a hysterectomy for some reason, you only have to have estrogen HRT. And estrogen HRT is not associated with an increased risk of breast

cancer. It's the estrogen and progesterone together. And I have to give you estrogen and progesterone together if you have a womb, because if I just give you the estrogen, then I'm going to increase your risk of womb cancer. But I can cancel that out with the progesterone. So you're going to get both of those together. 23 cases per 1000 women in the UK between the ages of 50 and 59. Those are the number of women who are going to get both of those together. 23 cases per 1,000 women in the UK between the ages of 50 and 59, those are the number of women who are going to get breast cancer anyway, okay? Add in HRT, you're going to get four more cases per 1,000. Now, that's about the same actually as the pill. And yet people don't worry about the pill and breast cancer, which I find very interesting. If you smoke, if you drink more than the recommended guidance of alcohol, that increases the number of cases by three and five per thousand respectively.

If you have obesity, by another 24, so it doubles your risk. So if you put it into context of things that you've already been doing potentially, that risk is really, really small. And really importantly, if you are somebody on HRT who gets breast cancer, you are more likely to survive. The all-cause mortality for women on HRT is lower than those not on HRT. And the reason is that you're more likely to have what we call a hormone receptor positive breast cancer, and that is easier to treat. So even if you were to be one of those unlucky in that really tiny risk, increased risk, so of 0.4 of a percent, then you're still more likely to do better. Other risks that people talk about, risk of stroke. The original study was about taking oestrogen orally and sort of now quite old fashioned

oestrogen and progesterone. If I give you your oestrogen in a patch or in a gel through the skin, there is no increased risk of stroke. And those are the two major ones that people worry about. What's it going to do for you? First of all, it's going to get rid of your symptoms. And those symptoms, we have to remember, are really impacting on personal lives, social lives, work lives, relationships. So we mustn't discount that sort of cost at the beginning. But also, I'm going to decrease your risk of heart disease.

I'm going to decrease your risk of dementia. And I'm going to decrease your risk of osteoporosis that leads to a mortality and a morbidity associated with things like hip fracture. So for many, many women, those risks outweigh the benefits. And the sort of the headline is this, if you're between the age of 50 and 60, the benefits of starting HRT really tend to outweigh the risks for most people. Starting between 60 and 70, the risks and the benefits are about equal. And starting HRT after 70, the benefits tend to be out 60 and 70, the risks and the benefits are about equal. And starting HRT after 70, the benefits tend to be outweighed by the risks. So we wouldn't generally start it. But no, I said start in all of those. If you start HRT within 10 years of the menopause, there is no defined stopping point as long as those benefits continue to outweigh the

risks. So if you develop breast cancer, yes, I'm stopping it. But as long as those benefits continue to outweigh the risks. So if you develop breast cancer, yes, I'm stopping it. But as long as your blood pressure is controlled and everything else is fine, for many women, there is no need to stop. Okay, that was a really good summary. So for women who choose not to take HRT or who fall into the bracket who cannot take HRT, what are some of the alternatives that they consider in terms of managing symptoms around the menopause so if your symptoms are just vaginal symptoms things like vaginal dryness pain during sex recurrent urinary tract infections then we can give very good vaginal lubricants and

moisturizers but also we can give a tiny bit of vaginal estrogen and that's although technically it's an HRT because it only works topically in that area, it doesn't get absorbed into the rest of the body and therefore has no risks at all. And even if you've had breast cancer, the oncologists are generally happy for us to give that without any worries. But we use other medications. So for example, we use antidepressants and we use anti-seizure medicines. And that doesn't mean that I think that you're depressed. And it doesn't mean that I think that you've got epilepsy.

We use these medicines for all kinds of things. And they can actually really work very well for things like flushes and sweats in particular. The NICE guidance talks, and this does work, they talk about CBT, cognitive behavioral therapy, which really has an impact on flushes and sweats. So there are lots of things that we can do. And for some women, it's a little bit of trial and error. But that doesn't mean that sort of you've tried one and now you think okay well nothing's going to work we've got lots of stuff in our armory yeah um and something a lot of women ask is if my periods are stopping

do i still need to take contraception yeah so the answer generally is yes so as i said the menopause is a diagnosis of retrospect i don't know that you've been through it until you haven't bled for a year. And for some women, their periods are going to go quietly and they're going to get lighter and further and further apart. And other women's periods rage against the dying of the night and they get closer together and heavier. And I don't know which one you're going to be.

But the rule of thumb is this. If you're under the age of 50 and you have been through the menopause, you need to use contraception for a further two years. If you are over the age of 50 and you have been through the menopause you need to use contraception for a further two years if you are over the age of 50 and you go through the menopause you need to use contraception for a further year and by 55 the risk is so small that everybody can stop but that only refers to the risk of getting pregnant the risk of stds is always there and the only thing that prevents those is a condom. Okay, that's a good reminder. So earlier on, you briefly mentioned when we don't have oestrogen,

the increased risk of certain conditions, such as osteoporosis and heart disease. What are some of the conditions that are related, that are more prevalent after the menopause? And what can we do to prevent them or protect ourselves so i think that lots of women think oh i've been through the flushes bit you know i've made it throughout the other side or didn't have any and they're lucky sort of 20 percent that don't have any and then they're often really surprised when they come back a few years

later with something and the medium-term symptoms tend to start off with those vaginal symptoms, recurrent urinary tract infections, constant itching, burning, and then very painful sex, which then adds to the loss of libido. And those, as I said, are often treated with a little smidge of vaginal estrogen. And then years later, we know from the evidence that it's the increased risk of dementias of all kinds not just blood pressure and blood sort of atherosclerosis which is the thickening of the artery so not just those forms of dementia but all forms of dementia heart disease and stroke and then osteoporosis now osteoporosis is firstly the one that you can do something about when you still got periods

and that's why um and i'm sure that Hazel's done lots of this before but the importance of calcium and vitamin D but also weight-bearing exercise every time you bang your foot on the floor essentially you're making your bones stronger there's a little bit of micro damage that then encourages the bones to lay down and repair and that's what keeps your bones strong and we need to have good bone density before we go into the menopause because once we're in it we're going to lose the protective effect of oestrogen on our bones and the other thing that women talk about and whilst as a medic we don't tend to actually talk about cosmetic things or aesthetic things i know that women are really bothered by them so you'll notice that after the menopause, where you lay fat down changes. So women,

before the menopause, lay down fat around their breasts and their hips. And after the menopause, they tend to lay it down more around their tummy in a sort of male pattern. Oestrogen is in your skin. It's what makes your skin sort of plump. And it affects the collagen structure. So you're more likely to develop wrinkles. You're more likely to be prone to sun damage, including things like sunspots, so hyperpigmentation, too much pigment in the skin. And so the kind of products that you would want to use on your skin

and the protection for your skin may well change. And women also notice a change in the structure or how their breasts feel because essentially the breast tissue itself is no longer being stimulated by oestrogen. And so what you're left with is the sort of the fat around that. And that's why women's breasts often lose their shape, they say. You know, people say, oh, my breasts are sagging.

And while we don't treat each of those things medically, as a sort of added bonus to HRT, women say that their skin continues to look great and that their hair is continues to be sort of lustrous and that's all oestrogenic effects and so whilst you can't start HRT because of your skin or your hair women would often say you know it was a little added extra yeah okay cool I think we've really covered, well, a whistle stop to her through the menopause and periods. But in addition to periods, something which I think causes a lot of confusion, maybe it's swept under the carpet a little bit, and there's still a bit of a taboo about it, is urinary incontinence. So I think most women know the symptoms, but it's helpful to run over the symptoms. does it happen and what can we do about it so urinary incontinence is really common after the menopause so common that there seems to be this idea that as you get older incontinence is normal that's not the case it's never the case as an adult that incontinence is normal and there's two kinds and both of them happen much

more often after the menopause the first is stress stress incontinence. That's the leaking a little bit when you cough, when you sneeze, when you jump on the trampoline with your kids, you know, when you run for the bus. And that is because there is a structure in the body called the pelvic floor muscle, which is like a hammock in the pelvis. And that hammock supports the organs of the pelvis. That hammock is aligned with estrogen receptors. And after the menopause, without that estrogen stimulus, it essentially becomes less bouncy. It's less elastic and it's less able to support those organs.

And then when you add in pressure from the abdomen, when you run, when you cough, when you sneeze, it means that the organs of the pelvis can sag below the pelvic floor. And that can give a little bit of incontinence. And it can also give prolapse when those organs sort of fall down, essentially. And that kind of incontinence is firstly treated with pelvic floor exercises and suddenly everybody sits up straighter and sucks in um yeah so everybody needs to be doing their pelvic floor exercises and sometimes we refer to women's health physio to really help with that

and so some people will need what we call biofeedback. So something that is inserted into the vagina and it just gives a beep when you're squeezing properly just so you get a little stimulus of I'm doing it right. Or surgery can help. And the second kind of incontinence is a bladder instability, an urgency incontinence. And that's often called key-in-the-door incontinence. So you're fine and you put your key in the door

and suddenly you can't wait. And you might not get to the toilet in time. So you're fine fine and then oops i need to go i've gone and that's treated with medication and also something called bladder drill where you generally very slowly train your bladder to increase the amount of time that it can hold urine for what you must not do which is what so many women do is they go i need to go to the toilet every 10 minutes i'm going to drink less and all that happens is that your bladder produces less urine, but it's still too twitchy. And so it still stimulates to less urine. And over time, it stimulates to less and less and less urine. And you're actually making the situation much worse. What we need to do is

fill that bladder and then train the bladder to get used to that. And sometimes you get a mixed picture of the two. But your upshot is, if you have incontinence, go to your GP. Yeah, absolutely. Okay, Philippa, thank you so much. That was so interesting, that conversation. I'm sure it's going to help a lot of women. I know there's going to be lots of people

who want to know where they can get your book. So where can we find it? So it's called The M Word, Everything You Need to Know About the Menopause by Dr. Philippa Kaye. And you can find it on Amazon and other online and real life bookstores. And you do lots on Instagram as well.

Yes. Talking about various different topics. So either on Instagram or on Twitter at Dr. Philippa Kaye. Wonderful. Thank you so much. Thank you. Thank you so much for tuning

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