EPISODE 46 INTRO
Welcome back. If you are just joining us, go listen to Part 1 first. It is Episode 45 and it will give you the foundation for everything we are about to cover.
For everyone who is back: last week, Dr. Jennifer Helft and I talked about what estrogen decline is doing to your pelvic floor tissues, why leaking during exercise is common but not normal, and why the pelvic floor is a whole-body pressure system, not just one little set of muscles at the bottom of your pelvis.
Today we are getting into two things I know are going to land differently than you expect. Prolapse, because I think most women have heard the word and have no idea what it actually means or whether to be concerned. And constipation, because if you have ever been told it is just hormones or just eat more fiber and felt like that was not the whole picture, Dr. Jennifer is going to explain exactly why that is not the whole picture. Let’s get into it.
PELVIC ORGAN PROLAPSE: WHAT IT IS AND WHAT TO LOOK FOR
Megan: So I’d really love to dig into pelvic organ prolapse because I think that this is fairly common and women are so ashamed, they feel like they’ve done something wrong, that there’s something wrong with their body. It seems like this is very common, especially after childbirth. Can you walk us through what that is and how this gets missed? It’s almost like women get their six-week checkup and then they hightail it out of there to take care of that little kiddo, and then all of a sudden they get into perimenopause and they’re like, why are things falling around? What’s going on here?
Jennifer Helft: Yes, a hundred percent. And I think just before I dive into the prolapse part of it, what you said is so important. While we are focused on menopause today, I think that what we experience as women across our lifespan is not educated to us enough in earlier stages where we can then start to think about what will happen. My own personality is like the planner: what can I plan for so I can maybe make something a little less difficult?
We don’t want to hyperfixate on it, but we do kind of want to give ourselves this idea of: I have had a child, things feel a little bit out of place, and not taking the answer of you just had a baby, give it some time. That answer might be true, but who’s to say that we can also help your body along? Let’s give it time by helping it through that time, not by leaving it alone for the next three months and seeing what happens.
And then we get engaged in motherhood and we forget about ourselves a little bit sometimes. And maybe if we’re lucky, we have more children if that’s what we desire. And then yes, what you just said is we get to this menopausal period and we’re like, well, crap. I remember feeling this when I had my first child, and I was told that it was okay, or that it would just keep healing. So if you’re someone who is listening and thinking, whatever stage of life that you are at, I feel this now, but I remember feeling it way back when: get the PSA out there to anyone that you know that is before menopause. Let’s just get this looked at and really help your body get to a place where we can maybe do a little bit more help in preventing how significantly some of these things will happen as time goes on.
Megan: I love preventative care. Anytime that we can get that out, share this with your friends. If you have a friend right now that you’re thinking of that is complaining about these exact symptoms or told you her birth story and this was part of it, share this episode with her. She needs to hear it.
Jennifer Helft: So pelvic organ prolapse: I think many of us women have heard the term, but maybe don’t understand exactly what it means or what’s happening. A pelvic organ prolapse is essentially when the muscles and the ligaments surrounding the pelvic organs, which for women are our bladder, our uterus, and our rectum, start to weaken over time. We get this sort of dropping, bulging, or protruding of that organ into the pelvic cavity space.
A lot of women will experience symptoms like pressure in the vaginal opening or a heaviness at the pubic bone or at the vagina itself. Some women will feel either kinesthetically, kind of like between their legs, rubbing between the labia, or physically feel with their hand a bulge that feels like it’s pressing on the opening of the vaginal space. This could also lead to difficulty in feeling like you can completely empty your bladder or completely empty your rectum when having a bowel movement, because the downward mobility of those organs is essentially taking up more space in that pelvic cavity and creating a little bit more of a barrier for successful bladder and bowel emptying.
But I also think one of the things a lot of my patients ask is: is it something I should be worried about? And my answer is, it depends. We have found in research and anecdotal evidence that the degree of the pelvic organ prolapse is not always directly related to the degree of symptoms. The prolapse itself is less worrisome than the symptoms that someone is experiencing because of the prolapse.
I have had patients who have a pretty mild prolapse but have pretty significant symptoms and have pretty painful intimacy and significant difficulty emptying their bladder. And I have had patients who can feel a bulge, but say: besides feeling it, I don’t really have any symptoms. So the point is: if your doctor has told you this is a mild prolapse, but you are saying it is six out of 10 affecting my day, I don’t care if it’s mild or not. The symptoms are there, and that is what we have to be focusing on.
THE POSTPARTUM GAP
Megan: And this is why every woman needs access to Dr. Jennifer or someone like her, because it’s this crazy idea of listening to a woman’s symptoms and believing her. So as you’re talking about this, I am literally envisioning this hammock with woven straps and some of the straps are a little bit loose and a little bit hanging down, and that’s kind of where something might slip through or fall through. And so this is sort of what is driving this prolapse, and this perimenopause picture can make that worse.
Jennifer Helft: Absolutely. That’s where the gap between pregnancy and menopause periods of time is: it’s all the stuff that we’re doing in between. But I’m on the side where I believe every woman after birth should have a pelvic floor check, because pelvic floor physical therapists are really the only providers that are able to marry all the things together and really look at the movement of that system from a functional place.
Megan: It’s like we all don’t get that PSA when we’re leaving the hospital: you should go see a pelvic floor therapist in six to eight weeks to follow up and see what’s going on.
Jennifer Helft: I’d love to know a raise of hands of how many people have actually been told that on their way out. I don’t think it’ll be very large.
CONSTIPATION AND THE PELVIC FLOOR
Megan: This constipation piece with perimenopause is a conversation I have with a lot of women. And when I say to them, have you also spoken to a pelvic floor therapist about this? People are like, what are you talking about? And I say, well, it can be diet, but it can also be physiological. I would love for you to walk us through how we could think about the difference between constipation that might be food and diet related versus something that might be a pelvic floor issue.
Jennifer Helft: This topic ties in so beautifully with nutrition because first of all, our nutrition is a big piece of good sound pelvic floor health in general. Constipation can become more common during menopause, and it’s the symptom that I think most of my patients are most shocked by. But the fluctuation or decline of these hormones can slow the digestive tract, where the drop of those hormones can cause a more sluggish or slower movement through the colon, making it harder to pass stool because that stool is spending a longer time in transit through the body.
Progesterone is a key hormone in this topic: its function is to help stimulate muscle contractions. As it declines, we don’t get that smooth muscle contraction that helps to push stool through the intestinal tract. And then estrogen assists with our cortisol regulation, so as it declines, our cortisol levels can rise and now we get this effect on digestion and digestive motility.
Now, if we link that back to what we know those hormone fluctuations are doing to the pelvic floor musculature itself, we have this stool that may be taking a longer transit path through the digestive tract. And then once we get to the bottom of that area of the pelvic floor, we have these tighter muscles that don’t really have a good ability to expand the way they need to. And that harder stool makes it a lot harder for the pelvic floor to really relax and open to let stool pass as it should. So then we strain, then we push harder. Now we mess with that intra-abdominal pressure all over again.
But I would also say that I don’t think one can happen without the other. I don’t think focusing on that pelvic floor perspective can happen without addressing what’s happening in the diet. Because we get these hormonal shifts that also alter the gut microbiome. And now we might be sensitive to different foods. And now fiber may not have really mattered, but now it really matters because we have these tissue changes and things aren’t moving so fast anymore. So I just don’t think that we can talk about one without the other.
Megan: I feel the same. Everything is so connected. And when I think about the amount of women that get lost in this early perimenopause phase, which is when progesterone steps down because she is the first to go, our entire digestive system is moved by peristalsis, which is muscle contraction and movements. So if we don’t have that progesterone, how do we move everything through?
And what you were touching on with the cortisol and estrogen combination: when we are stressed out and we are putting foods in our body, we know that we are not in rest and digest if our cortisol is up. If you’re not in rest and digest, you’re chomping down that food, there’s no saliva, there’s no digestive enzymes, and then you’re just dumping a whole bunch of chunked up food into your stomach with nothing to break it down. And then it’s like Lucy and Ethel on that conveyor belt with the chocolates and it just gets backed up and then everyone’s not doing their job and then we’ve got a big old mess.
Jennifer Helft: So more times than not, the feeling of constipation and incomplete emptying tends to be coupled with some kind of extra effort to try to get stool out. I ask my patients: how much work do you have to do to feel like you have a complete emptying of your stool? Or how long are you sitting on the toilet? Some people are just there for 10 to 15 minutes. That’s too long. Even a piece of that, with prolonged time sitting to let something pass, feeling like you have to wipe over and over again because there’s something there that won’t really make its way fully out, is significant.
I also tend to notice that people have a lot more abdominal discomfort with constipation. A lot of my patients will describe these kind of abdominal spasms or gurgly motions or tightening and contracting of the belly muscles. Constipation as it’s defined is typically characterized by hard or lumpy stool or a bowel movement that happens more than three days apart.
Megan: So what I’m hearing, Dr. Jennifer, is that we should be having quick bowel movements. We walk in, pants come off, our butt is on the toilet, and it’s like peeing. It’s not this prolonged experience. We’re not having time to read on the toilet, we’re not having time to mess around on our phone, we are not straining. It should be as simple as what my partner likes to call them: a phantom poop. So a phantom poop is probably where we want to go. That’s our goal. Hot girl pooping, right? We’re just phantom pooping here.
And the other piece of it is that if you are not quickly having a bowel movement that is smooth on a regular basis, meaning every day or every other day, that is a sign that you may have some constipation. And this may be worth a conversation with a pelvic floor therapist and taking a look at dietary interventions that could help you move things along, make sure that we are hydrated, and make sure that that transit time is not backing us up.
MID-EPISODE: BOOK A CALL WITH MEGAN
Before we get into the next part of this conversation, I want to take a quick second because I am working on something and I need your help to build it right. If you have been listening to this series and thinking, okay, I get it, I am in perimenopause, now what the heck do I actually do, that is exactly the problem I am trying to solve. And I want to hear directly from you. What has been the hardest part of getting support? Where have you hit walls? What has felt impossible to figure out on your own?
I am booking 30-minute calls and I want to be really clear about what this is. I will spend the first ten minutes asking you questions. Your experience, your frustrations, what you wish existed. And then the last twenty minutes are yours. Bring me your questions about perimenopause, your labs, your symptoms, your confusion about what your provider said or didn’t say. I want to help and I want to listen. These calls are free. The link is in the show notes. Book yours and let’s talk.
EPISODE 46 OUTRO
Hot girl pooping. Phantom poop. You heard it here. That is the standard and we are holding ourselves to it.
Part 3 is next week and it is the one I think a lot of you have been quietly waiting for. We are going into painful sex after menopause, the self-blame spiral that happens when providers shrug, and what it actually sounds like to advocate for yourself when the system keeps sending you home. Dr. Jennifer gets fired up. I get fired up. It is a good one.
One more thing before you go. I am building a program to help women go from I think I am in perimenopause to I actually know what to do next, and I want to build it around the real problems you are running into. Not what I assume they are. Yours. If you book a free 30-minute call with me, I spend the first ten minutes asking you questions about your experience and what has been hard. And then the last twenty minutes are completely yours. Bring me every question you have been sitting on. About your symptoms, your labs, what your provider said, what to try first. No agenda, no pitch. Just a real conversation. The link is in the show notes. I would love to talk with you.
