Urologist Dr. Angelish Kumar on How to Laugh (Sneeze) and Work Out Pee-Free
Show Snapshot:
Got bladder leaks, UTIs, or a fear of being seated in the middle row of an airplane or movie theater?
Meet Dr. Angelish Kumar, a urologist and certified menopause practitioner, who has ideas for combatting all your irksome bladder issues. We dive into the top 4 common bladder complaints (and why NO ONE talks about them) and the impacts of menopause and aging on bladder and vaginal health.
Bottom line: it IS possible to laugh, sneeze, and workout pee-free. If you have a bladder, this show is a cannot miss!
In This Episode We Cover:
1. Managing the 4 most common bladder issues for midlife women.
2. A whopping 1 in 3 women suffer from urinary stress incontinence. Why pelvic floor therapy can be an easy, noninvasive fix, plus other treatments.
3. The 411 on irksome UTIs which can increase (or begin) in midlife.
4. How menopause can produce a constellation of annoying (and painful) symptoms that can fly under the radar and go untreated.
5. Why too many women silently suffer embarrassing urinary leakage issues (and ideas for being pee-free).
6. What normal bladder health looks like (and when to go in search of help).
7. All the ways menopause and estrogen-loss impact your bladder and vaginal health.
8. Exercises, supplements, medications, cranberry juice, bladder training, surgeries and more.
Quotable:
The bladder, the pelvic floor, the urethra, and the vagina are all estrogen sensitive. As women progress further into menopause, and the tissue lacks estrogen for a longer and longer period of time, you get thinning of the vaginal tissue. You lose your nice healthy vaginal microbiome, you then become more prone to UTIs, the urethra and the bladder start to feel more irritated, and your collagen starts to degrade. As you lose collagen around your urethra, you may leak more easily.
Women have been suffering with vaginal dryness and very painful intercourse, urinary tract infections, leaking urine, overactive bladder symptoms. A lot of women will say that it’s just this sort of general awareness of their bladder and urethra and vagina that they never used to have. So many women come in and they’ll say, “No one can figure out what’s going on with me,” and all of these problems that they’re describing link back to one thing. Sometimes they have actually been prescribed estrogen cream, or topical estrogen by another doctor, but they didn’t use it because the package insert it was terribly frightening because the FDA requires the same warnings as they do for estrogen that’s used for hormone replacement therapy.
Word of Mouth. Angelish recommends:
I think the one tool to maintain urinary and vaginal health is a good female urologist. There are male urologists who also specialize in female urology, there are gynecologists who have done a fellowship in urogynecology who do the same thing. So, my advice is, find a specialist, either a urologist or urogynecologist who actually specializes in bladder and vaginal health because a lot of women think that they should see their general gynecologist who is probably a wonderful person and a wonderful doctor but may not specialize in things like urinary incontinence, recurrent UTIs, and pelvic organ prolapse.
More Resources:
For Pelvic Floor Health:
Find a Pilates studio or instructor
Every Mother exercise app and programs
For Recurrent UTIs -- PAC supplements:
Follow Angelish
Transcript
Katie Fogarty (00:04):
Welcome to A Certain Age, a show for women on life after 50 who are unafraid to age out loud. I’m your host, Katie Fogarty.
Filmmaker Alfred Hitchcock once said that the length of a film should be directly related to the endurance of the human bladder, which means I should be watching very short films. Very, short films. Today I’m joined by a guest who is helping us make it through long movies and life with better bladder health.
Dr. Angelish Kumar is a board-certified urologist and a certified menopause practitioner. If you have an overactive bladder, leakage, painful sex, and fear of organ prolapse, do not go anywhere. This show is for you. Welcome, Angelish.
Dr. Angelish Kumar (00:50):
Thank you so much.
Katie (00:52):
Thank you. I am really excited to be talking all things bladder and vaginal health with you because this is front and center for me and so many women. But before we dive in, I’m curious, I want to know how you started off in this field. When I went in search of a female urologist to talk to, I learned from Google that only 8% of urologists are actually women. So, how did you wind up in this field?
Angelish (01:18):
Yeah, you know, it’s interesting. I was in medical school and I was doing my rotations as a third-year medical student and you kind of are in love with every field and every area you rotate through. You go, “Oh, I want to do this.”
So, when I did my surgery rotation, I remember my first week was actually vascular surgery and I was in these really cool, like, carotid artery operations and they were fixing these abdominal aortic aneurysms and it was very intense. We would be in the operating room for 8 hours and the time would just fly by. So, I knew that I definitely wanted to go into a surgical field, and then it turned out that my next rotation was urology.
When I was, you know, spending time with the urologists, I really found a group of people who were great doctors, who were really nice people, who also were doing really fascinating surgeries and had this whole range of different types of procedures that they could do from open surgeries to laparoscopic or robotic surgeries, to endoscopic surgeries, like for kidney stones. So, I knew that it was a great field and that I would definitely find a lot of fun things to do. [laughs]
Katie (02:47):
I am amazed by all of these different options because when I think of urology, I don’t even really think of surgery, but that actually makes total sense.
Angelish (02:56):
Yeah, it’s interesting because it is a surgical field and there’s such a broad range of types of surgeries. I think most people think about prostate cancer, kidney stones, and circumcisions. But you know, we do surgeries for things like incontinence and pelvic organ prolapse, like you mentioned. As well as lots of different types of procedures for the bladder and so there are so many different things that you can do in urology.
Katie (03:28):
So, what are the top reasons that somebody would come to you? Is it for surgery, or what’s a more sort of common complaint you might hear from women in midlife?
Angelish (03:38):
So, I’ve actually focused my entire practice on women in midlife. [laughs]
Katie (03:44):
Good! Because we need your help.
Angelish (03:46):
They have so many urologic problems. But, yeah, so, I think the things I’m seeing most of are stress incontinence, which is leakage when you cough, laugh or sneeze. A lot of women find that they can’t exercise because they leak urine when they exercise and it’s actually extremely common after pregnancy and childbirth. About one-third of women suffer from stress incontinence.
I see a lot of recurrent urinary tract infections, which is also a very sort of distressing problem that many women can have throughout their lives and for some women, it starts happening around midlife because it can start happening around the time of perimenopause and so that’s certainly a big one. Especially during the pandemic where, you know, it’s a problem that you can’t put off. You really need to be seen and get it taken care of and do all of the sort of, preventative things you need to be doing so that you don’t continue to need antibiotics.
I see a lot of overactive bladder, as we discussed. When you need that seat close to the bathroom and you’re running out of the movie theatre because two hours is just too long for you to hold it. So, that’s a very common problem with urinary urgency and frequency. Some women actually do leak before they reach the toilet which is a very distressing problem to have and something that we can certainly help out with.
And then I also see something called genitourinary syndrome of menopause, which is sort of a constellation of symptoms where there’s urinary urgency, frequency, you kind of feel like you have a UTI, but then you get your urine test and you don’t; maybe some burning with urination, vaginal irritation; this just, general awareness of the whole area. And that happens in women, usually after menopause and it goes extremely under-recognized and under-treated. So, I’m very vigilant about recognizing that and treating it.
Katie (06:04):
That sounds like a combination of those top three, because you talked about stress incontinence, UTIs, and overactive bladder, and that fourth thing you gave me is like, all that and a bag of chips. It’s like rolled in together. That doesn’t seem fair.
So, let’s start with stress incontinence. Because when you talked about how women sometimes experience leakage during exercise, I immediately flashed to a good friend of mine from college who used to absolutely adore running, and then I remember seeing her at one point and saying, “Why aren’t you doing that any longer?” and she shared it was because like she was like having to go to the bathroom or leaking urine each time. And neither one of us knew that there was something you could be doing about it. So, how do you tackle stress incontinence in your female patients?
Angelish (06:48):
So, the first line of therapy is usually to see a pelvic floor physical therapist. Many women are told, “Oh make sure you do your Kegels.” And actually, the data shows unequivocally that when women are just sort of told to go home and do kegels, it’s typically not as effective as when they go and actually see a pelvic floor physical therapist. So, you know, definitely, the first line of management is to do pelvic floor physical therapy, with a pelvic floor physical therapist. I usually recommend once a week for 6 weeks and then once you’ve done that, then you can start doing the exercises at home.
In my practice, a lot of women have already done that, or they’ve found that it was effective for sort of the period of time they were doing it, and then some months went by and they were leaking again and they wanted something that was a little more definitive. And then, you know, you get into procedures. We have a couple of procedures that are very effective for stress incontinence, one is an injection that we do in the urethra with a water-based gel, and it basically helps the urethra form a tighter seal. So, if you can imagine when you go to the dermatologist and you have fillers done for your wrinkles to sort of plump up the tissue, we can do the same thing on the inside of the urethra where we’re sort of plumping it up so that it is closing more tightly and it prevents you from leaking.
Katie (08:36):
That’s so cool, I’ve never heard of that. Is this the botox for the bladder or is that something different? Because I’ve seen that on websites.
Angelish (08:44):
Yeah, good question. So, botox is actually for overactive bladder. We do do botox injections in the bladder, but that’s not for stress incontinence, that is for overactive bladder. This agent is called Bulkamid and it’s great because it’s a simple office procedure, it works immediately, there’s no downtime as far as having surgery, and it's effective in about 80% of women, so it’s very effective for a procedure that is so minimally invasive.
Katie (09:20):
And how long does that last for? Because that sounds fabulous.
Angelish (09:24):
So, it’s interesting because it’s the first… We call those types of injections in the urethra, we call them urethral bulking agent injections and it’s the first bulking agent that actually has good data up to five to seven years out. And so, in about 75% of the patients who do well with the initial injection, they are able to maintain those results five to seven years out, but we don’t have longer-term data than that, so past that I can’t say. But you know, it works pretty well, and it does tend to last. And I think for people who end up needing another injection, because it’s not a surgery, you don’t have to go to the hospital, you don’t have to have anesthesia, you just have to come into the office, it’s not such a big deal to get a top-up injection if you need that.
And then for patients who have more severe stress incontinence, we have a surgical procedure which is called the sling. That’s where we place either a piece of your own native tissue or a piece of mesh under the urethra, to basically help restore the support of the urethra, and that also is extremely effective. It works well, but it’s a surgery, so you do have to have anesthesia, it’s typically done in a hospital or in an ambulatory surgery center, and you know, of course, the risks of having surgery are a little bit higher and there is a recovery period. I think for a lot of women, that recovery is very, it’s a big deal because there’s like, no heavy lifting and nothing in the vagina and that’s impractical for…[both laugh]
Katie (11:15):
Of course. If you want to have fun or do other things. But I’m curious-
Angelish (11:20):
No, I just mean like, you know, if you’re getting your period and you wear a tampon for the time of recovery you’d have to wear a pad. If you have a four-year-old and you’re told you can’t lift your four-year-old for six weeks, it’s a big deal to have that recovery. So that surgery works really well, but it is a surgery.
Katie (11:43):
Sure. So, you’d said that this is something, candidates for this are people who maybe aren’t having effective treatment from the bulking or from the pelvic floor therapist, so how many women…so this is not for people who are just having like, I sneeze and I leak urine. Define who is the right candidate for this.
Angelish (12:04):
So, women who, you know it depends how often you leak when you sneeze. So, you have some women who say, "I’m wearing three panty liners a day because if I sneeze if I laugh if I run to catch the bus or the train, I leak, my pad is wet.” So, those women, if they’ve done pelvic floor physical therapy and it’s not helping, then you definitely want to consider doing a procedure like a bulking agent or a sling. If you have a woman who says you know, “I leak once a month if I jump on a trampoline with my kids,” then that’s someone who I think can be managed more conservatively. The slings are slightly more effective than the bulking agents. So, if you have a patient who says, I want to be substantially improved, you know, the bulking agent is going to work well, but if you have a patient who is saying, “I want to do the most definitive thing, I want to be”-
Katie (13:10):
I want to be on a trampoline. [laughs]
Angelish (13:12):
…completely dry and I’m willing to have surgery,” then, you know, I think a sling is a better option.
Katie (13:18):
Okay, so that’s for people who are really committed to their trampoline activities.
Angelish (13:22):
Right. [laughs]
Katie (13:23):
This is so fascinating. Okay, we’re going to come back in a minute and discuss UTIs, but first, we’re going to take a quick break.
[Ad break]
Katie (14:53):
Okay so, we’ve discussed stress incontinence and the three different options. I want to dive into UTIs because I know that this is something that has plagued me in the past and I’m being selfish. I’ve got you here, and I want you to help me figure out how to make sure these things go away and don’t come back. But I’m pretty confident that a lot of our listening audience has also struggled with these so, how can you help us?
Angelish (15:23):
Well, so with urinary tract infections, a lot of the history matters. So, it matters: are you getting them after getting sexual activity, are you on the birth control pill, are you post-menopausal? You know, you have to sort of take into consideration different risk factors. So, for women who are postmenopausal, the lack of estrogen in the vagina contributes a lot to why it’s very easy to get urinary tract infections. The bacteria actually come from the GI tract, for most UTIs. So, most women have heard of bacteria called E. coli, that’s the most common cause of urinary tract infections. And they come from the GI tract and they sort of colonize the skin around the perineum, between the anal opening and the vaginal opening. And when the vagina lacks estrogen, the vagina actually becomes a good reservoir for bacteria that are able to cause urinary tract infections. And so, in postmenopausal women, I always make sure that we’re placing estrogen in the vagina. That helps to foster a healthy vaginal microbiome which is very protective against UTIs.
Katie (16:44):
And so, how would you do that? What is your recommendation for introducing or reintroducing I should say, estrogen into the vagina?
Angelish (16:52):
So, we use a cream. We call it topical estrogen. It comes in a cream form, it comes as a tablet. You essentially apply it in the vagina, you can do it with a fingertip or with an applicator, you can do it with a swab. It doesn’t matter how, as long as it gets in there. And so, it’s not systemic hormone replacement therapy. It doesn’t raise blood levels of estrogen back to premenopausal levels as it would if you took, oral estrogen pills or if you used a transdermal patch. Those are forms of hormone replacement therapy. When you use local estrogen, just in the vagina, that is what we call topical estrogen therapy and it doesn’t carry the same risks as hormone replacement does. So, it’s extremely safe and it’s a very important tool that we have to help prevent UTIs in post-menopausal women.
Katie (17:53):
So, what about, I’d always heard, because I used to get UTIs quite frequently, pre- when I still had my period, premenopause, perimenopause. I’d always heard that you should void after intercourse, is that something you recommend even in midlife and post-menopause?
Angelish (18:11):
Yeah, you know studies don’t really corroborate that. When they’ve actually looked at whether urinating after sexual activity helps to prevent UTIs-
Katie (18:25):
Wow, I’m so disappointed. [laughs]
Angelish (18:28):
I know. Well, it’s not, I’ll tell you what-
Katie (18:30):
Maybe it’s a placebo effect, I feel like it makes a difference but I guess it doesn’t. That’s so fascinating.
Angelish (18:34):
You know what, I agree with you, I think it does make a difference. They just haven’t been able to establish that when they look at two groups of patients who do and who don’t. But I think that there’s absolutely no harm in urinating after sex and it might help. You know, most people are going into the bathroom at some point anyway, and so, you know I think it makes absolute sense to urinate after. I’ve certainly had patients who have said that’s made a difference in them getting UTIs. One thing, post-coital UTIs are extremely common in women, so much more common than women think. And one thing that’s very helpful is something that’s called post-coital prophylaxis where you take just one pill of an antibiotic immediately after sex, that’s extremely effective in preventing UTIs in sexually active women. So, that’s something if we can establish that pattern if the UTIs are definitely happening after sexual activity, I certainly favor that approach.
Katie (19:48):
Okay, so that’s really cool. So, I’m curious. UTIs are so, so annoying and frustrating [Angelish laughs] and painful, and uncomfortable but…
Angelish (19:57):
They really are.
Katie (19:57):
So they’re hard to ignore, but do they cause any damage besides just making you insane? Are they bad for your bladder?
Angelish (20:07):
They actually do…so, do they cause permanent damage to your bladder? No, not usually. But they do, the process of having an infection, it does cause basically acute injury to your bladder. The way your bladder defends itself when you get a urinary tract infection is by sort of shedding the lining and shedding the cells which are infected. So, what happens is, you have all of these inflammatory mediators and nerves which get upregulated, and then you have healing factors that basically come to heal the repaired, the injured tissue. And so, some women, you’ll see, have symptoms of the inflammation, even after the infection is gone. And in fact, there are some studies that show that estrogen is actually important in facilitating that healing process. So, your bladder is getting injured, but then it’s very quickly trying to heal itself, and usually, you don’t sustain prolonged injury from urinary tract infections. And sometimes, of course, it’s only a small percentage of people, but people who end up getting infections that go up to the kidney, if you have recurrent episodes of kidney infections, that certainly can cause scarring in the kidney, so you want to avoid that.
Katie (21:39):
Okay, all right. So, we’re definitely working hard to avoid UTIs. We hear a lot about homeopathic remedies like making sure you’re drinking a lot of water and flushing out your systems, drinking cranberry juice. Is that an old wives tale, or is that helpful?
Angelish (21:55):
So, drinking water is definitely helpful. There was actually a study that showed that women who increased their fluid intake by 1.5 liters, particularly their water intake, by 1.5 liters per day, who were getting recurrent UTIs were getting fewer UTIs per year when they did that. So, I do think that’s a helpful strategy.
Cranberry juice is an interesting question. The reason why we talk about cranberry and UTIs is because cranberry has an enzyme which is called PAC. That enzyme helps to prevent bacteria from sticking to the lining of the urinary tract, which is sort of the first step to how they cause an infection. The issue with juice is that it may not be concentrated enough and you may not be able to drink enough to get a therapeutic level of those PACs. You know, I think Ocean Spray is doing some studies on their brand of juice, I think they may want to market some kind of a juice product where they can say that it’s beneficial for UTIs.
There are supplements that are good quality, high PAC supplements. The issue with supplements is that they’re not regulated by the FDA, so anyone can just put anything on a label. So, if you take a supplement, you really want to use one which is third-party tested to ascertain that it actually has what they’re saying that it has. So, for UTIs, cranberry products that have 36 milligrams of PACs are beneficial. I certainly use that in my practice where I have patients take a product either once or twice a day as a part of a UTI prevention strategy.
Katie (23:53):
Okay cool. And is that over the counter? Or is that something you have to prescribe?
Angelish (23:57):
So, the ones that I use are over the counter because they’re essentially, yeah, cranberry supplements. They’re over the counter, but I’ve sort of vetted which ones I think are high quality.
Katie (24:10):
I would love it if you could share those with us or pass them along to me afterward because I want to put those in the show notes. People always want resources.
Angelish (24:18):
Yeah, so the ones that I typically recommend are Ellura, I’ve been using their product in my practice for about I would say five or six years. And then the other brand which has a high-quality PAC supplement is Utiva. So, those are really the two brands that I recommend.
And you know, I have patients who will come in and they’ll say, I’m using this Whole Foods brand or whatever it is and since I’ve been using it I haven’t been getting UTIs. You know, that brand that they’re using may be perfectly good, I just don’t know. Because unless I’m testing it in a lab I have no idea. And so, it doesn’t mean that the brands that I recommend are the only good brands, they’re just brands that I trust based on the company’s rigor that they’re using in the product that they’re putting forward.
Katie (25:18):
Okay, terrific. So, we’re going to move on, even though I’m fascinated with UTIs since I feel like I’m a mini-expert, so I really appreciate all of this new information, thank you.
All right, moving onto number three, the third complaint: overactive bladder. So, every woman who is listening right now thought, "I have an overactive bladder." Can you actually start by defining that for us? When should we be hitting the panic button? [Angelish laughs] What’s normal? And what should we be worried about?
Angelish (25:53):
Okay, so let’s see. So, overactive bladder is basically, it’s a syndrome where you experience symptoms of urinary frequency, urgency, and nocturia, which means waking up at night to urinate. And so, frequency, if you are urinating more often than once every three hours, that’s considered frequent. So, if you’re going every two hours, every one hour, then you have frequency, that’s pretty often. And of course, that’s related to how much you drink and a lot of people will say, “Well, after I have my morning coffee I pee two or three times, and then for the rest of the day I go every three or four hours,” and that’s pretty normal actually.
Urgency, is the feeling of being unable to make it to the bathroom. Like, you feel a strong sense of urgency to urinate and you feel like if you don’t get to that bathroom quickly, it might leak out before you get there. And the classic example of that is you know, you’re coming home from work, you know you have to go to the bathroom, you figure you’ll go as soon as you walk in the door, and then you’re putting your key in the door and the urgency intensifies and it actually starts to dribble out before you sit on the toilet. So, that’s called urge incontinence. When urge incontinence is happening and you’re actually leaking, that is definitely when it is a bad problem and you should certainly be seeing a urologist.
Nocturia is when you wake up at night to urinate and that usually goes along with frequency because however much your bladder is holding during the day is reflected at night. Frequency and nocturia can be very bothersome even if there’s no leakage of urine. The sort of, distraction and annoyance of constantly having to think about the bathroom is very distressing for a lot of people.
And so, we have a range of options for overactive bladder symptoms, which can be: behavioral therapy, fluid modification, pelvic floor physical therapy like we talked about for stress incontinence, which can also be helpful for overactive bladder and urge incontinence. You can actually use your pelvic floor muscles to either defer the urge to urinate or help you hold it when you have that strong urge and you feel like you’re not going to make it to the bathroom. And then we have medications that help to relax the bladder and allow it to store urine more comfortably. As you mentioned, we have botox injections, which help to also relax the bladder muscle, and then we have various types of nerve stimulation which help to sort of calm the signals from the bladder that you constantly have to pee.
Katie (29:14):
Okay, it’s so funny that you’re saying relax the bladder, because frankly, sometimes I wish my bladder were more uptight. [Angelish laughs] This is serious, we need to be paying attention here, we need to make sure we’re focused on doing our job. I don’t want a relaxed bladder.
Angelish (29:33):
When I say relax the bladder, I’m talking about relax the bladder muscle so it’s not squeezing and telling you, “I wanna pee, I wanna pee.”
Katie (29:41):
Got it, I love it, this is good. I’m getting educated, this is really smart. So, training, I get. It sounds like you’re working on muscles or maybe practicing training your bladder to go longer and longer and physical therapy we covered at the beginning. So, talk to me a little bit about medications. Are these over the counter, is this prescription, are there sound effects, do you have to take them forever? What does that look like as a solution?
Angelish (30:07):
So, medications are not over the counter, they are prescription. There are two types of medications. The first type, that general group, they’re called anticholinergics. They basically help the bladder store urine more comfortably. They do have side effects like dry mouth, constipation, there are some emerging data about the risk for dementia in patients who take anticholinergic bladder medications for long periods of time. So yeah, they actually work pretty well, but it is a concern in terms of how long you’re going to be on them. So, sometimes what I’ll do is, I’ll use medication for 6 months or a year while a patient is doing bladder retraining or pelvic floor physical therapy, and then we’ll try to wean it off.
Sometimes women also have other problems that are contributing to their overactive bladder. For example, recurrent UTIs, genitourinary syndrome of menopause. So, if there are any sort of underlying causes, we try to address those, and then you know, if there are side effects with medication, which for many people there are — the dropout rate for taking medication is pretty high — then we start moving onto other non-medication therapies, like botox.
I should say, there’s another type of medication which is called Myrbetriq, which is not an anticholinergic and doesn’t carry that same side effect profile, it’s I think better tolerated. So, I usually will try to start with that if we’re using medication, but it becomes an issue of insurance coverage, and of course, the insurance companies want to cover only the cheapest, oldest medications that have the worst side effects. So, that becomes an issue as far as what we can prescribe.
Katie (32:27):
Those darn insurance companies [Angelish laughs]
So, tell me a little bit more about the constellation, where you had said that in menopause there’s this, I’m going to mispronounce it, genit-
Angelish (32:40):
Genitourinary syndrome of menopause.
Katie (32:42):
Okay, that is a mouthful. That doesn’t sound like fun at all [laughs]
Angelish (32:48):
Yeah, and you know, it’s extremely underdiagnosed and what happens is, the bladder, the pelvic floor, the urethra, and the vagina are all estrogen sensitive. And so, as women sort of progress further into menopause and the tissue lacks estrogen for a longer and longer period of time, you get sort of thinning of the vaginal tissue, like we talked about for recurring UTIs. You lose your nice healthy vaginal microbiome, you then become more prone to urinary tract infections, the urethra and the bladder start to feel more irritated as a result of the lack of estrogen, and collagen, when you lose estrogen, your collagen also starts to degrade. So, you start to use collagen around your urethra, you may leak more easily, and you know, so it’s sort of this constellation of irritative urinary and vaginal symptoms. It only got a name in 2014 which is just crazy because, if you think about men who’ve had issues as a result of low testosterone, they’re surrounded by five doctors and everybody’s ordering tests and we need to get penile dopplers now. [both laugh]
Katie (34:17):
This is an emergency, this thing is not working.
Angelish (34:22):
Right, and women have been suffering from vaginal dryness and very painful intercourse, urinary tract infections, leaking urine, overactive bladder symptoms. A lot of women will say that it’s just this sort of general awareness of their bladder and urethra and vagina that they never used to have. And so, it’s interesting because so many women come in and they’re sort of like, “No one can figure out what’s going on with me,” and all of these problems that they’re describing sort of link back to one thing. Sometimes what happens is they have actually been prescribed estrogen cream, or what we talked about, topical estrogen by another doctor, but they didn’t use it because of the package insert, it was terribly frightening because the FDA requires the same warnings as they do for estrogen that’s used for hormone replacement therapy. So, you get this medication and you open it and it’s like: may cause heart attack, stroke, dementia, uterine cancer, breast cancer…
Katie (35:40):
Or it may solve your problems, right? When you’re outlining all of the things that you just shared that often go wrong when estrogen declines and the thinning of these tissues, I can’t understand why this isn’t like a four-alarm fire. [Angelish laughs] Everyone should know that they need to be worrying about these things.
Angelish (36:04):
In my office it is, but yeah, it goes very underrecognized. I think that there is more awareness of it now among doctors. I think women are increasingly proactive about their health and I think part of the issue was that when the Women’s Health Initiative study when those results first came out in 2002, where the increased risk for thromboembolic events and cancers seemed to happen in women who were on hormone replacement therapy, everyone became really afraid of estrogen. So, women were going around with these symptoms, they’re being given bladder antispasmodics, medications that sort of numb the bladder, they’re being given a lot of different things that treat the symptoms but not treat the underlying problem. As we discussed, using the cream in the vaginal area, it’s extremely safe and very effective for this issue.
Katie (37:12):
What about oral estrogen, do you recommend that if cancer is not a risk or a concern? Wouldn’t that be effective as well?
Angelish (37:21):
So actually, interestingly for genitourinary syndrome of menopause, systemic hormone replacement therapy is not as effective as just sort of going right where the money is and putting the cream directly on the tissue. So, oral estrogen or transdermal estrogen for systemic hormone replacement therapy is appropriate in women who are within 10 years of menopause, who don’t have certain risk factors in terms of like breast cancer history and cardiovascular history. And that can really help with things like sleep quality and mood swings, the hot flashes, it can be protective. Estrogen when given early on can be protective for osteoporosis and brain function so, those are good reasons, but different reasons from genitourinary syndrome of menopause, and for that, the cream actually works best.
Katie (38:31):
That sounds very simple too. There are so many wonderful purposes that provides.
Angelish (38:35):
It is.
Katie (38:36):
This is so fascinating. I have learned so much about my own body since I’ve launched this podcast. I’m not kidding. I have learned so much about issues that are plaguing women in midlife and myself from having conversations with you and other doctors who have been on this show. I’m telling you, this is something that I really feel flies under the radar in terms of my own healthcare but even in the conversations I have with friends. We spend a lot of time talking about skincare and retinol and everyone wants to talk about a laser treatment they did or their favorite sunblock. But none of my friends are talking about bladder issues. Why? People are talking to you about it because you’re a urologist. [both laugh] Why aren’t more women having these conversations?
Angelish (39:26):
You know, it is so important that these issues come to the forefront of people’s conversations and that women seek appropriate medical care for debilitating problems like urinary incontinence. I think that it’s such a taboo topic for so many women, especially you know, when it comes to stress incontinence after childbirth. Leaking urine, it’s such an embarrassing problem to have and you know, women are-
Katie (40:06):
But it’s common, right? Didn’t you share that it’s common?
Angelish (40:10):
Yeah, like one-third of women after pregnancy and childbirth suffer from stress incontinence so it’s extremely common and you know, a lot of women feel that what happens to their body when they have a baby it’s not as important as focusing on the baby, making everyone happy, having this sort of, picture of a perfect life. Stress incontinence doesn’t fit into that picture. I think it’s the expectation, especially in our culture, that we’re supposed to just bounce back after we’ve had a baby and that our body just brings us back to where we were at before we were pregnant. There’s just a huge pressure on women to act like everything is perfect and everyone is happy. And so, I think it gets swept under the rug.
Katie (41:16):
I think that happens with aging also, Angelish. You think about the fact that people are not aging like J. Lo and they look amazing and people, I think there’s a fear of aging in our culture. People don’t want to admit they’re getting old. So, all of a sudden if you have “old people problems”…
Angelish (41:33):
It’s true. And when people come into the office and they’ve had episodes of urge incontinence, or they’re having stress incontinence or overactive bladder symptoms, it is something people often say is, “I’m not going to be in diapers like an 80-year-old, am I?” So, you’re right, it is partially a fear of aging and all the physical decline that comes with that. But I think that particularly for women, it’s interesting to me because I think certainly if a man were to develop urge incontinence or men develop problems from an enlarged prostate, they develop problems with urination from that, and they don’t seem to have a problem going to see a urologist and getting it taken care of in the best way that they can. And I feel like when women are having these issues, first of all, as you said, most women don’t even know that there are, that urologists take care of female bladder issues, number one. And that there are actually female urologists who they probably would feel more comfortable with. A lot of women speak to their gynecologists as sort of their first line. And if their gynecologist refers to them a urologist then that’s great, but if their gynecologist doesn’t refer them, then they kind of think that, okay well…
Katie (43:02):
It’s over.
Angelish (43:03):
…that there’s nothing more to be done here, you know? I’m stuck with this.
Katie (43:06):
Well, we’re changing that. We’re totally changing that conversation.
Angelish (43:09):
[laughs] I hope so.
Katie (43:09):
This has been so fascinating. We’re nearing the end of our time but I do not want to let you go without talking about organ prolapse because I still remember the very first time I learned about it and I was shocked. Like, how is that even possible? But can you please quickly walk us through what it is and most importantly, how do we prevent this?
Angelish (43:32):
Sure. So, pelvic organ prolapse is basically when the bladder, the uterus, or the rectum essentially lose the support that keeps those organs nice and sort of, high in the pelvis. And you have connective tissue and ligaments surrounding your bladder, urethra, vagina, and your rectum that are essentially keeping those organs in place because those are functional organs. When you have a bowel movement, you bear down and when you bear down, your rectum doesn’t fall out of your body.
Katie (44:12):
Thank God! [laughs]
Angelish (44:15):
And thank God for that [laughs] and so, with pregnancy, childbirth, some people have genetic collagen defects, smokers have very poor collagen quality, it can be in athletes who are bearing down a lot and putting a lot of pressure on their pelvis. If that connective tissue on those ligaments becomes stretched out or weak, your pelvic organs essentially start to sag. And the space that they can sag down into is the vaginal canal. So, women will perceive like a sensation of a bulge in their vagina and if it’s coming from the front it may be a bladder, if it’s coming from the top it may be a uterus, and if it’s coming from the back wall it may be the rectum.
To prevent pelvic organ prolapse, I think it’s really important to maintain excellent core and pelvic floor strength. So, during pregnancy you want to be doing your prenatal pilates, you can do pelvic floor physical therapy while you’re pregnant. Every Mother is an app which has amazing at-home regimens for core strength and also for post-
Katie (45:38):
Okay, I need to stop you right now because I did none of those things [Angelish laughs] and I have three kids and they are 20, 18, and 14. What can I do now? I need an emergency intervention because I do not want that to happen. For anyone who did not do prenatal pilates and we’re in our fifties, what do you recommend?
Angelish (45:57):
So pilates, even now, is still really helpful. When you do pilates, you have this sort of zipping up sensation of your transversal, and elevation of your pelvic floor, and that is very protective. So, I still recommend doing pilates. Pelvic floor physical therapy, of course, is very effective in maintaining pelvic floor strength and keeping those organs where they are, and preventing them from falling out. But chances are unless you already have some prolapse that you don’t want to get worse if you’re this far out into having kids, it’s unlikely you’re going to just develop prolapse later on in your life.
Katie (46:51):
Okay, good. So I’ve dodged that bullet. Thank goodness. This has been so wonderful. I could keep talking to you but our time is wrapping up.
I want to ask you two things though before I let you go. You have given us so much information, I’m linking to all the recommendations in the show notes. Is there one product, tool, or a resource that you really think women should know about for managing urinary, vaginal menopausal issues, or anything that you think is relevant?
Angelish (47:21):
Well, I mean, that’s a very broad question [laughs]
Katie (47:23):
That’s a big one. [laughs]
Angelish (47:28):
I think the one tool to maintain urinary and vaginal health is a good female urologist.
Katie (47:36):
I love it, I agree. I agree.
Angelish (47:38):
That would be the only resource that I can recommend that would encompass all of that in one thing. So, yeah. I think find a female urologist, wherever you are. There are male urologists who also specialize in female urology, there are gynecologists who have done a fellowship in urogynecology who do the same thing. So, my advice is, find a specialist, either a urologist or urogynecologist who actually specializes in bladder and vaginal health because a lot of women think that they should see their general gynecologist who is probably a wonderful person and a wonderful doctor but may not specialize in things like urinary incontinence, recurrent UTIs, and pelvic organ prolapse.
Katie (48:40):
Great advice. So, how can our listeners keep following you and your work?
Angelish (48:46):
The best way is through my website. My website is www.womensurologynewyork.com. I wrote all the content about all of these conditions that we talked about and the treatment options, all the content on my website was written by me, not by you know, a medical writer or anything like that. And so, I give my sort of honest opinion about the data, the risks, and benefits and I’m constantly doing things like blog posts on things like herbal medications for overactive bladder and things like that. So, that would be the best way. I actually always feel upset that more people don’t, you know, they look at my website to get the phone number of the office and things like that and you know whenever I talk about treatments with patients I’m like, “Did you read my website?” And they’re like, “No.” [laughs]
Katie (49:41):
Well, we’re changing that as well. I’m going to link to those resources in the show notes. Dr. Anjalish Kumar. Thank you so much for being with me today.
Angelish (49:49):
Thank you so much for having me, it was really fun to talk with you.
Katie (49:52):
This wraps A Certain Age, a show for women over 50 who are aging without apology. If you enjoyed this week’s show, please head to Apple Podcasts, Spotify, or wherever you listen to review the show, because reviews help us grow. And share this show with your friends who complain about their tiny bladders. You know, the ones who always need the aisle seat on the airplane or at the movies. They are going to thank you.
Join me next week when we dive into midlife funny moments, with comic Carole Montgomery, creator of the showtime comedy special, Funny Women of a Certain Age. Special thanks to Michael Mancini who composed and produced our theme music. See you next time, and until then: age boldly beauties.