INTRO
Okay, I have to ask you something. Have you ever been invited to a trampoline park and said no? Or gone and just quietly stayed on the sidelines? Because I did. I went to one with my entire extended ex-in-laws and was so excited. It was my idea. But once I got there, I got tired pretty quickly. Because something about bouncing like that without a completely empty bladder meant damp underwear, and that was just not something I was willing to risk in public.
I talk to women who skip jumping during workouts, who avoid dancing a little too hard, who laugh carefully, who have quietly built their entire life around not leaking, and they think this is just what their body does now. It is common. I promise you, it is very common. But as you are about to hear from my guest today, common is not the same as normal, and normal is not the same as inevitable.
Today I am so excited to introduce you to Dr. Jennifer Helft, a pelvic floor physical therapist and the founder of Modern Pelvic Health Physical Therapy on Long Island. She has been a physical therapist for nine years, starting in orthopedics before finding her calling in pelvic health. She works with people experiencing pelvic floor dysfunction, pregnancy and postpartum concerns, pelvic pain and core dysfunction, and she takes a whole body approach to care. She is on a mission to make sure women stop accepting symptoms that are treatable just because nobody told them help existed.
I want to tell you something before we get going, my peri friend. I have worked with a pelvic floor therapist before. It was a referral from my gynecologist for painful sex, and I went. But I left the experience more confused than when I walked in. There was consent and the session happened, but there was very little communication about what was going to be done, why it was going to be done, or what we were actually working towards together. I want to be fair, I think that could have been handled better from both sides. I was young, I didn’t know what questions to ask, and I didn’t know that asking them was even an option. Now I know better, and part of what made me so eager to have this conversation is that Dr. Jennifer is exactly the kind of provider I wish I had walked into that day. I am so glad you’re here. Welcome to Mornings with Megan.
COMMON IS NOT THE SAME AS NORMAL
Jennifer Helft: Thank you so much for having me. I’m so excited to just let everybody know what is common but not normal.
Megan: That’s where we’re going to start. Dr. Jennifer, that phrase: common does not mean normal. What do you mean by that? And why is it so important for perimenopausal women to hear it?
Jennifer Helft: It’s important because I think far too often in our medical community in general, but more specifically in our women’s health medical community, we are told that certain symptoms are just going to occur because we have hit a certain age, or certain symptoms are just going to happen because we have previously been pregnant or given birth. It’s delineating the fact that just because we see those things tend to happen does not mean that they are supposed to happen. And more importantly, if they do happen, they are occurring because something is miscommunicating within the body system, and that there is help for that.
And I think once we start to hear that these symptoms occur because they’re more prevalent as we have hit different milestones in our lifespan, the words common and normal tend to sort of blend and people consider those words to be the same. Because it’s so common that it’s being talked about with all of your friends around a cup of coffee means that it must be normal because everyone’s experiencing it. And I think we just have gotten very comfortable with saying to ourselves, because my physician has told me it’s common, because I am hearing that everybody else is experiencing it, that must mean that I’m supposed to experience it. And I just have to sit and live with it because I gave birth or because I am now in this menopausal age. And I’m tired of people saying that they wish they knew that they could get help sooner.
Megan: Resonates with me so much because so many women that I work with in the space also have a similar experience, not from a pelvic floor therapist specifically, but just in general, this whole women’s healthcare space where things that are common but not normal just keep being expected. It’s common to have PMS. It’s common to have pain with intercourse. It’s common, it’s common, it’s common. Well, just because it’s common doesn’t mean that it should be happening. So what are the most common things women come to you having been told by their doctors, by their besties, by Dr. Google, that you have to immediately help them unlearn?
Jennifer Helft: I think some of the most common things that I hear are that after giving birth, pain is just supposed to happen when you have intercourse. Or during menopause, pain is just supposed to happen because of these physiological changes. That leaking urine is just going to happen because I have hit a certain age. Physicians saying, well, this is the stage of life that you’re in. This is what we’re going to expect when we see that we start to have hormone fluctuations. When you have given birth to three children.
And so once again, those things can happen, but it’s so important to delineate the things that we don’t have control over versus the things that we do have a little bit of control over. On the whole, I would say avoiding activities because it’s going to allow their symptoms to happen, like your trampoline park intro, resonates with me so much. Women saying that they can’t run around with their grandchildren or pick up their grandchildren. This uptick in chronic lower back pain that’s always been there that now all of a sudden feels so much worse because you hit menopause. But then no one is being told how to address those things and that there is a way to address those things. Leaking urine, feeling a new sudden urgency to urinate that they never felt before. And constipation coming out of nowhere, which is so prevalent in this span of life, that just gets that stamp from someone that said this is just what tends to happen when we enter this phase of life.
Women are shocked when I explain to them the connection between why those symptoms are happening, what those hormone fluctuations mean, and that there is this very powerful but petite set of muscles in our body that respond to all of these changes that we do have some control over.
Megan: Dr. Jennifer, are you saying that I don’t have to be constipated, have damp underwear, have painful sex, and change my entire life because my entire abdomen and lower half of my body is in pain for the rest of my life? Yes! I’m so pleased that that is where we’re at. There are so many solutions that we have, and women just need to know. It’s like we need a better PR machine to get the information out there. So walk us through what estrogen decline does in the pelvic floor tissue specifically and how that structural change can leak, for lack of a better word, into urinary incontinence and perimenopausal symptoms.
WHAT ESTROGEN DECLINE DOES TO THE PELVIC FLOOR
Jennifer Helft: So one of the biggest changes is that menopause is marked by the change in our hormonal balance. We do see this decline of estrogen and progesterone, specifically estrogen dropping, which reduces the muscle volume, the plumpness of the tissues, the flexibility and elasticity of not just the pelvic floor muscles themselves, but also the vaginal tissue. So the plumpness of the labia and the integrity of that tissue. What tends to happen is it leads us towards this weakening and stiffening or tightening of these muscles, which just makes it a little bit harder for the pelvic floor muscles to do their job. And then what we start to see is weakened support of those muscles and those ligaments of things like the bladder and the urethra, which is what can lead to incontinence.
We start to see a reduced muscle tone, which is essentially the ability of the muscle to sense the need for it to engage when necessary in response to what the rest of the pelvic floor system is doing. And a decrease of that support can lead to things like pelvic organ prolapse. We start to see thinning of our vaginal tissues, decreased lubrication or vaginal discharge. And then with that tighter, more stiffened pelvic floor musculature, that is where things like pain with intimacy can start to really be prevalent.
Megan: So it’s kind of like those stretchy yoga pants you have in the back of your closet that used to hold their shape and now they have those little pills and when you stretch them out they get a little crackly and a little crinkly and they’re not going quite back. So that’s kind of what’s happening to our pelvic floor and our vaginal tissue, and that is playing into this prolapse and this urinary leakage. And so I’m going to guess that leaking during exercise may be very common, but it is not normal.
LEAKING DURING EXERCISE: COMMON BUT NOT NORMAL
Jennifer Helft: Yes. Exercise: what I talk about a lot of times with my patients is this idea of pressure management. This goes into trying to understand what that pelvic floor system’s role is, what its job is. What I mean by our pelvic floor system is when our pelvic floor musculature that sits at the bottom of our pelvis works together with our glutes and our deep hip rotators and our abdominal muscles and our diaphragm and where our foot gets support from the ground, and where our upper spine has the ability to rotate. While all of those things are working together, one of the side effects of that in a positive way is that our body is able to manage pressure appropriately.
And so when we start to see these hormonal changes happen, and we start to see what effect that has on the bottom of that system, those pelvic floor muscles, and their ability to stay elastic and contract when they need to and support when they need to, when that is now compromised, we have a much bigger issue with that pressure system being able to regulate appropriately. So we add something like exercise, like strength training or running or rowing, and we are now asking that system that is kind of starting to work at a little bit of a disadvantage to still manage that same amount of pressure.
Leaking during exercise is underneath the category of something called stress urinary incontinence, where we are putting our body under a more physically stressful or physically demanding activity. And when our body can’t manage that force and that intra-abdominal pressure during exercise, we start to lose the capacity of those muscles doing their job. A phrase that I use with my patients quite a bit is when the pressure above becomes too great, what’s underneath can’t really manage what happens. And the result of that is usually losing urine when we don’t want to.
Megan: Dr. Jennifer, I want to touch on something you just said that blew my mind. You just talked about the pelvic floor being connected to where our foot hits the ground all the way up to where our shoulders are turning and our diaphragm. This is amazing. So it’s kind of like the throughway of every part of our body. All of the muscles are connecting through this pelvic floor. So if something is pulling up or pulling down, it sounds like the pelvic floor can be affected by that.
WHY KEGELS ALONE ARE ALMOST NEVER THE ANSWER
Jennifer Helft: One hundred percent. I think one of the most common fixes suggested during this phase is: well, I’ve got to do more Kegels, right? I just gotta strengthen my pelvic floor a little bit more. And so the problem with that is that just an isolated action at the area of the body that already is being overwhelmed by hormone fluctuation, tightness, and decreased capacity of muscle activation, we’re now asking it to try and do more work than it’s already doing. And it’s just not going to work out in our favor because our pelvic floor muscles were never meant to work in isolation.
If you look all over social media, so many different pelvic floor therapists are using that phrase now because it’s just so true. It was never meant to work in isolation. It doesn’t respond by itself, it responds to the actions of what the other areas of our body are doing. So when I evaluate a patient, I’m looking at so many more things besides just the internal pelvic floor examination. Sometimes it’s even more important to look outside of the pelvic floor and watch my patients’ breathing mechanics and watch how they’re walking, how their foot is striking the ground. Do they have a really flat foot? Do their knees hyperextend? Are they really settling into the front of their pelvis where there’s this big sway back in their lower spine?
Nine times out of ten, it’s those things that end up being a bigger part of the pie chart than just the pelvic floor musculature itself. And usually when we start to break down and look at all of those things, it’s like this window into now I understand why the pelvic floor is working so hard.
Megan: It’s like the pelvic floor is the outlet. What you’re saying is making so many connections in my body when I think about all of the things that were happening in my body when I went to a pelvic floor therapist, the diaphragm problem because I was stressed all the time and I was tensing up my shoulders and everything was there and that short quick breath work from being stressed out and being on alert all the time. All of that plays a role in this connection. And even TMJ, clenching and tightening your jaw, so connected to the pelvic floor.
Jennifer Helft: Goodness, yes.
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 45 OUTRO
Okay, we are going to pause right there. I could genuinely talk to Dr. Jennifer for the rest of my life and not run out of things to cover. In Part 1 we covered common versus normal, what estrogen decline is actually doing inside your pelvic floor, why leaking during exercise is not something you just have to manage around, and why Kegels are so often the wrong answer, or at least an incomplete one.
Part 2 is dropping next week and we are going into two things I know are going to surprise you. Prolapse, what it actually is and whether you should be worried about it, and constipation, because yes, your pelvic floor has everything to do with what is happening in the bathroom, and Dr. Jennifer is about to explain exactly why.
And before you go: I am building something new and I need your help to get it right. If you have ever felt lost in perimenopause and wished someone would just tell you what to do next, I want to hear your story. The link to book a free 30-minute call with me is in the show notes. The last 20 minutes of that call are entirely yours. Come with questions. I will see you next week.
