Your Pelvic Floor Deserves More Attention Than You Give It with Dr. Lynn Gray-Meltzer
Show Snapshot:
Bladder leaks. Painful sex. A pelvic pressure you've never mentioned to a single person. Somewhere between a quarter and a third of women deal with a pelvic floor disorder, and most just quietly manage it instead of actually fixing it. Dr. Lynn Gray-Meltzer, a pelvic health physical therapist, is here to pull the whole topic out of the shadows.
In this episode:
The two types of urinary incontinence (and why they need different fixes)
How tight — not just weak — muscles cause pelvic dysfunction
Real prevention strategies for pelvic organ prolapse
What to actually expect at your first pelvic floor PT appointment
About Dr. Lynn Gray-Meltzer: Dr. Lynn Gray-Meltzer is a Doctor of Physical Therapy and board-certified specialist in orthopedics and women's and pelvic health. Her work champions preventive, primary care PT, treating issues like incontinence, prolapse, and painful sex before they're dismissed as just part of aging.
Show Links:
Follow Dr. Gray-Meltzer:
Quotable:
"Kegels definitely aren't for everybody — many women I work with actually have short, tight pelvic floor muscles. Think of them as being stuck halfway up the elevator."
Transcript:
Katie Fogarty0:02
Welcome to A Certain Age, a show for women who are unafraid to age out loud. I'm your host, Katie Fogarty. Beauties, if you have ever leaked when you laughed, winced during sex, or sprinted to a bathroom like your life depended on it, do not go anywhere. We have an episode that is going to change your life, because here's a shocker: tens of millions of women in the US — I'm talking somewhere between 25 and 30% of adult women — suffer from at least one pelvic floor disorder, think urinary incontinence, fecal incontinence, painful sex, pain with pelvic exams, even pelvic organ prolapse. But here is the rub: there is an entire specialty dedicated to solving exactly these problems, but too many women don't know about it, and too many women don't use it. So today we're exploring that solution in depth. We are doing an A-to-Z primer on pelvic floor therapy, and how it can help ease pelvic dysfunction, painful sex, bowel changes, constipation, leakage, and more. And listen up: nearly 50% of women will develop pelvic organ prolapse at some point in their life. Let's make sure it's not you. Our guest today is Dr. Lynn Gray-Meltzer, a doctor of physical therapy and a pelvic health specialist. She is a leading voice in the pelvic health special interest group of the American Physical Therapy Association of Massachusetts. I got to interview Lynn this spring at the Let's Talk Menopause Menoposium in Boston, and I was so knocked out by all her smart, actionable advice. I knew immediately that I wanted to have her as a guest on the show. Welcome to A Certain Age, Lynn.
Dr. Lynn Gray-Meltzer1:51
Hi, I'm so glad to be here.
Katie Fogarty1:53
I am excited for this conversation. I launched this show almost six years ago, and during those six years, I received multiple DMs from women talking about things like painful sex, bladder leaks — things that they're a little embarrassed to bring up, maybe with their own doctor or with their own girlfriends. So this is such an important conversation, but let's begin at the beginning. What is the pelvic floor, and why is it so central to bladder control, sexual function, and even bowel health?
Dr. Lynn Gray-Meltzer2:22
The pelvic floor is quite complex. It's layers of multiple muscles at the base of your pelvis, or pelvic outlet — that's why it's called the pelvic floor. It is more than just muscles, as well. It's a network, or web, of fascia, ligaments, connections with the pelvic organs, and connections all the way up into your abdomen through deep fascial chains, up into your rib cage and respiratory diaphragm as well. The deep layer is like a hammock — it helps lift and support your organs and manage downward pressure. And the outer layer is a little bit like a gatekeeper: it helps close and open to let urine flow out fully, easily, and comfortably; let easy bowel movements happen; and let the vagina soften and stretch for comfortable intercourse and comfortable pelvic exams, ideally.
Katie Fogarty3:20
So when it works well, everything is humming along. But we get to midlife, or maybe we have some children when we're a bit younger, and all of a sudden we're experiencing things like peeing when you sneeze. Sometimes there's pain with vaginal penetration, even difficulty achieving orgasm. People sometimes have poop or gas that escapes without warning. These are all symptoms of pelvic floor dysfunction, which is truly life-disrupting. Yet I know from our conversation in Boston, I know from talking to the women in the show privately in my DMs, patients are often reluctant to bring this up with a doctor. What's keeping women from coming to you and other practitioners?
Dr. Lynn Gray-Meltzer4:00
I'm so glad that you're bringing up barriers to talking openly about these problems and getting help. Here's some of the barriers that I encounter. One is definitely embarrassment. This is such a sensitive personal issue that many times I see people who were afraid or embarrassed to tell their GP, their primary care provider, that they were leaking stool. They think it's more of a personal failing, like, "I did something wrong, I haven't taken care of myself, I'm gross," versus realizing that it's a medical issue and they deserve rehabilitation. Also, misinformation — a lot of women, unfortunately, were told that you've reached a certain age, or you've had some babies vaginally, these things are common. But just because they're common doesn't mean they're normal, and doesn't mean that they have to suffer in silence. They deserve to be told there's help, there's treatment, there's care pathways. And then the third thing is just knowledge. Sometimes people are referred to pelvic floor therapy, but they don't know where to go to get expert care, or there's long wait lists, or it's expensive. So sometimes people just turn to online search, and there is some really great information out there, but it can be overwhelming and confusing.
Katie Fogarty5:26
And so for a patient who is looking for some of that online information, where would you direct them, and where would you direct them to find a trained pelvic floor specialist?
Dr. Lynn Gray-Meltzer5:36
So there are two really great search tools online. One is through Herman & Wallace — they have a provider directory. And also, through the American Physical Therapy Association, they have a "Choose PT" find-a-provider directory where you can search by specialty. In this case, you'd put in pelvic health or pelvic floor, and you can also put in your zip code to see who's in your area and what level of continuing education certification they have, so you have a sense of exactly how expert this person is in pelvic floor therapy.
Katie Fogarty6:16
Okay, fantastic resources. I will be sure to link out to those in the show notes. So let's get into some of the nitty-gritty. We touched on the sneeze piece at the top of the show, which gets a lot of coverage in pop culture — there's memes, it's just something that people are used to hearing. Urinary incontinence is common, and there's nothing funny about bladder leaks, because it can interfere with things like — I had a friend who quit running because she was leaking while she was running — and we want to be able to dance and jump and enjoy ourselves and laugh without feeling like we're wetting our pants. I think there are two types of urinary incontinence. I would love for you to walk through what they are, and what a woman can be doing about it if that's something she's experiencing.
Dr. Lynn Gray-Meltzer6:56
You're absolutely right, there are two main types of urinary incontinence. The best known type is stress urinary incontinence. Now, this doesn't mean stress in terms of emotional stress — it means a physical pressure stressor. So that's the classic laugh, cough, or sneeze causing a leak. What happens, for example, when you cough is that your respiratory diaphragm, which is a big dome-shaped, umbrella-shaped muscle at the base of your lungs, pulses downward as you quickly suck in and then expel air. This sudden downward pulse of the respiratory diaphragm shifts some of your abdominal organs downward onto your pelvic organs, like your bladder. So basically, your bladder almost gets a quick squeeze, like a water balloon, and if that water balloon has a pinhole in it, and that pinhole isn't shut tightly and quickly, urine is going to get squeezed out. So ideally, when you cough, laugh, or sneeze, and there's that downward pulse of pressure, the deep layer of the pelvic floor quickly lifts the bladder to keep it a little bit tipped over the pubic bone, where it's nice and secure and stable, and then that outer layer does a quick squeeze, like shutting a door. But sometimes, if the muscles either aren't strong enough or they lack the coordination to squeeze with just the right timing, that's when urine can get pushed out. The other category of incontinence is called urge incontinence, and sometimes this can show up just as a high level of urgency and frequency before it reaches the point of actually leaking. The classic version, or the way it shows up in everyday life, is that somebody is rushing to the bathroom and feels this out-of-control urge surging like a wave, and without their control, the urine starts to leak out — maybe when they're just getting into the bathroom or pulling their pants down before they're actually sitting on the toilet. In more extreme cases, this urgency turning into an actual leak can come on further away from the toilet, when the brain starts to think about or anticipate peeing. Classic examples would be arriving in the driveway, putting a key in the door, or hearing water running when you're washing dishes.
Katie Fogarty9:29
Lynn, I feel like you've been following me around. Honestly, everything that you're describing is like, wait a minute, I've had all of this.
Dr. Lynn Gray-Meltzer9:38
Yes, so this isn't always simply a strength or coordination issue in the pelvic floor — it's more complicated in many ways. When the bladder stretches and fills with urine, a signal is sent up to the brainstem. There's a little area called the pontine micturition center. I think of this area like the switchboard of controls in a tower at an airport. So when that switchboard lights up with incoming signals that the bladder has some urine in it, the brain should be the boss. It's like the person in the control tower, the air traffic controller, who's reading all the messages and then deciding what message to send back out to the pilot in the airplane — or, in this case, the bladder. So if you're not actually at the toilet, your brain should be able to say, "Hey, urge, calm down, go away, this isn't a good time to send that let-down response." But sometimes habit changes, hormonal changes, situational things like running water, or being in circumstances that you strongly associate with urination, can make the brain lose control of that signaling process, and the brainstem sends a signal back down to the bladder and makes it squeeze, and some urine gets forced out. The good news is that there is something called bladder retraining and urge-deferral strategies, where you can teach the brain to be the boss of the bladder again.
Katie Fogarty11:16
And so, what are some of the strategies?
Dr. Lynn Gray-Meltzer11:18
Here's a little checklist to practice. First, you want to recognize when it could be a false urge. It's normal to have to pee, if you're well hydrated, about every two to three hours. So if you've peed, say, just an hour ago, and you feel this urge ramping up, you want to take a deep breath and tell yourself, "This is my body just being hypersensitive, hyperaware of what's happening in the bladder, but there's no way this is actual maximum fullness." So that first strategy is just recognizing this is a false urge, taking a deep breath, and reassuring yourself that there's no way your bladder is actually maximally full. The second thing is: don't rush. Of course, there's a tendency when you feel that uncomfortable urge to run to the toilet, but the movement and the anxiety around that rushing usually just makes the urge worse. So you want to hold still. If there's somewhere to sit down, you could sit down and put physical pressure on the perineum — that's the center of the pelvic floor. Or, if there's nowhere to sit down, you could just hold still, pause at the door — don't start running through the doorway. Then, while you're in that pause, you're going to do about three to five pelvic floor contractions, because pulling that pelvic floor in and up cues the bladder that it's not time for that let-down response. It's not necessarily that you're trying to get stronger in the moment — it's more like giving the body a cue that it's not time for the urine to come out. We can talk later about what a good pelvic floor contraction should feel like.
Katie Fogarty12:58
Yeah, well, these are fantastic tips.
Dr. Lynn Gray-Meltzer13:00
But the fourth thing I want to get in — the fourth thing is distraction. You don't want to keep thinking about peeing. It might seem like a good idea to use positive self-talk and tell yourself, "I can hold it, I can do this," but you're still thinking about peeing, and that's going to drive you to have a stronger urge to pee. So, distraction: spell your name backwards, count backwards by seven, immerse yourself in a task. Let's say you're pausing at the doorway — you could take out your lip moisturizer and put some on, and then calmly walk to the bathroom. So that fourth one is distraction. And finally, if you need to, you can proceed to the bathroom, but stay calm while you do so.
Katie Fogarty13:47
I'm distracted by this idea of calmly applying lip gloss and then moving to the bathroom. It's a great visual, and it's something I think that we can all practice and incorporate into our lives, because what you've just outlined is so common, and these are great tools to help tackle that. Let's talk about something that may be less common — or even if it's not less common, it's certainly less talked about — which is fecal incontinence. I think that sometimes people might be surprised to learn that the pelvic floor is also involved with things like our bowel movements, holding in gas, and constipation. Walk us through what we need to know about the link between pelvic floor dysfunction and those issues.
Dr. Lynn Gray-Meltzer14:29
This is a great question, and I feel like anything with gas and stool oftentimes comes with even more embarrassment than the urine piece. So I'm really glad you're bringing this up. Certainly, many people associate the pelvic floor with the sensation of stopping a stream of urine, but actually, over half the pelvic floor sits behind your sit bones, wraps around the anus, and goes all the way back and anchors on your tailbone — so the pelvic floor muscle group that helps support the bladder and vagina is absolutely also involved in supporting the rectum, that's the pouch that stool gets stored in, and regulating how it comes out, but also how it's stored. Very similar to how I talked about the pelvic floor and bladder, the deep layer helps lift and support the rectum, and there's a deep muscle called the puborectalis that's a little bit like a lasso — it slings all the way from the pubic bone, all the way to the back of the pelvic floor, wraps around the rectum, and goes back to the pubic bone on the other side, like a long U. When that muscle in that deep layer is ideally a little cinched, a little tight, when you're upright and moving around, it keeps the rectum a little kinked, like a garden hose, so gas or a little soft stool can't accidentally just slide out with gravity. And then the outer layer is where the actual anus is, so we have our internal and external anal sphincter — that again is like that final gatekeeper. But it's really important that we have all these layers working to support the shape of the rectum, as well as keep that final gate closed.
Katie Fogarty16:16
Are there things that we can do to help keep these layers intact and doing their job? We love the idea of them working effectively, of being that strong lasso, holding things together until we want to release them.
Dr. Lynn Gray-Meltzer16:29
Yes, absolutely. Let me walk you and your listeners through more of the support and storage end of things, and then we can come back to what's supposed to happen when we want more of that relax-and-release — when you do want things to come out on the toilet — because we don't want a partial bowel movement with something left behind. So, for strengthening, a few things are key. First, it's important to realize what a good, full pelvic floor muscle contraction, or Kegel, should actually feel like. You don't want to just think about stopping a stream of urine, because the center of the pelvic floor is actually back near the anus. You want to think about squeezing and lifting the anus first, like you're holding back gas. Or, sometimes people will imagine: if I put a little golden marble at the anus, you want to vacuum that marble up inside you and store it up in the rectum — that's what you want to feel, sucking in and up. And then the next sensation you want to feel is like you're pulling a little weight — or sometimes people say a little blueberry — up into the vagina. You don't want to smash it; you more want to feel that squeezing and lifting up towards the top of your head. And then, finally, you can feel a little pinch or squeeze in the front, like stopping a stream of urine. But you really want to work on that deep lift coming from the back, which again should feel more like that squeezing and lifting, like sucking gas back in, or sucking up a little golden marble. But you don't want to stop there. Sometimes I see people who say, "Oh, I tried Kegels and they didn't work for me." It's really important, just like any other muscle in the body, that you practice a gradually progressive strengthening program. So if you're having trouble doing a pelvic floor contraction, you first want to start lying down, practicing 10 quick squeezes — think about what you'd do if you coughed hard and felt like gas or urine was about to shoot out, you'd do a quick, strong squeeze for one second. You want to be able to do 10 of those, but you also want to do 10, 10-second-long, medium-effort holds that just feel smooth and controlled — almost like you squeeze and lift your anus and vagina up, up on a little elevator, hold steady, steady, steady for 10 seconds, and then release it, release it, release it. Once you can do that lying down — 10 slow ones, 10 quick ones — then you want to move to sitting. When that gets easy, after a few weeks, you want to move to standing. And then you want to start incorporating these contractions into function. The pelvic floor is the floor of the core. So if you're squatting to lift something — for example, whether it's at the gym or hoisting a kid or a bag of mulch — you want to exhale through the effort of that lift and pull those pelvic floor muscles in and up to support your pelvic organs.
Katie Fogarty19:21
This is a great setup that we can begin to incorporate into our own lives. I love the steps, where it increasingly becomes a bit more difficult based on our body's position. How often are we doing these? Are we still doing 10? Are we working up to a greater number? And is this something that we do until function restores, or is it something that we should be doing for the rest of our life? What is the cadence you recommend?
Dr. Lynn Gray-Meltzer19:44
That's a great question. Very similar to training other muscles: if we're at the point where we're practicing harder contractions — maybe you've practiced just nightly in bed at first, getting a sense of what it feels like to relax and contract your pelvic floor system. Say maybe that's the first four weeks, where you worked every day on 10 repetitions lying down. Then you got to a point where you did 10 repetitions sitting, and now you feel really confident that you know how to relax and contract your pelvic floor — you're through that early training phase. Now, say you're going to practice standing, and you're going to practice holding a pelvic floor contraction coming up from a squat — that's going to be a lot harder on your muscles, it's going to create fatigue. So when you're at that phase, maybe after you've been practicing for four to six weeks, you want to practice about two to three sets of 10 contractions every other day, or roughly three days a week. The reason is, when you get to the point of those more difficult upright contractions, or contracting with movement, like coming up from a squat, you're going to stress and strain your muscles, and where you actually get strong is on your rest days, when your muscles are recovering, repairing, and rebuilding from that stress and strain you put on them.
Katie Fogarty21:08
We have a fantastic blueprint. Thank you so much for walking us through that. We are heading into a quick break, but when we come back, I want to talk about painful sex, and I want to talk about some of the other common issues that maybe don't get as much airtime — chronic pelvic pain, vulvar pain, pelvic organ prolapse, and more. We'll be back in just a minute. Lynn, we're back from the break. When we went into it, you gave us a fantastic roadmap about how we can train our pelvic floor muscles and make them work more effectively. I know from researching for the show, sometimes one of the issues with pelvic floor dysfunction is actually muscles that are too tight. When that is the issue, what is a woman experiencing?
Dr. Lynn Gray-Meltzer21:49
I'm so glad you asked about this, because Kegels definitely aren't for everybody, or at least aren't the starting point. Many of the women I work with, especially in midlife — because lower estrogen creates tighter, stringier, drier tissue — actually have short, tight pelvic floor muscles. Think of them as being stuck halfway up the elevator, so they're trying to do contractions, but they're really only twitching and moving a little bit in mid-range, and they also can't relax and release through full range. So when that happens, oftentimes people are experiencing entryway pain with intercourse. They might feel like they just can't tolerate penetration, or sometimes they can barely tolerate penetration, but then feel almost like their vagina has gotten short — like something's being hit or tweaked internally. Also, constipation is a huge one. I know we talked about how to support and hold stuff in, but if you can't relax and release the deep pelvic floor, as well as that outer, gate-like outlet area, your poop can't slide out, and you can get constipated and have something called outlet dysfunction.
Katie Fogarty23:02
So how do we relax and release? Because sign us up for that. We want that.
Dr. Lynn Gray-Meltzer23:08
I'll give you a few simple things that you could practice at home. One technique is called pelvic balloon breathing. You picture a giant balloon inside your abdomen, low belly, with the tip of the balloon going all the way down to your pelvic floor — that tip ending at the vagina and anus — and it helps to picture it in your favorite color. When you inhale, you want to picture the air flowing into that internal balloon and gently expanding the walls of the balloon in all directions. So you're inhaling, maybe picturing smelling your favorite bouquet of roses or some other delicious smell, and that balloon inside you — in your low belly, in your rib cage, in your back, all the way into the vagina and anus — is gently expanding, blooming open. And on the exhale, the air is flowing back out your mouth, like blowing through a straw or fogging a mirror, and then the balloon just gently shrinks inward. You're not trying to contract or suck anything inward — you're just feeling the belly passively deflate, maybe the pelvic floor moves inward slightly.
Katie Fogarty24:25
And again, what's our cadence on this? Are we doing this in the morning, at night? Do we ramp up and increase our reps as we move forward?
Dr. Lynn Gray-Meltzer24:34
This isn't something that you need to think of in terms of increased reps the same way you would with strength, but it is helpful over time to get better at lengthening the breath. Most women I work with, at first, can only inhale and exhale for maybe three to four seconds, but a great goal over weeks or months — not in a single session — is to work on being able to inhale and exhale for eight to 10 seconds each. This can be great to mix into a bedtime routine, because it's great for calming our nervous system as well. And the more familiar we get with this relax-and-release technique for the pelvic floor, the more we can also use it as needed — say, during entry for intercourse, or during speculum insertion for a pelvic exam. Another great way to help the pelvic floor with this relax-and-release concept is using tools. Just like if your hamstring was really tight and you went to stretch it and it felt really stuck, you might massage it, you might roll it, you might use a massage gun. Those things might be a little intense for the pelvic floor, but there are vibrating tools — whether they're specifically for pleasure, those are like sex toys, or there are some that have more of a medical look and feel, called vibrating wands and vibrating dilators. Dilators, in particular, come in progressive sizes, and you can use them at night in bed, or whenever is convenient for you. You lubricate them well, and slide in a comfortable size — you don't go to the biggest one first in the progressive set, you start with one that's a comfortable size — and you just leave it in for 10 minutes to get a gentle, low-load stretch. And if it vibrates, all the better, because that's going to help stimulate tissues, increase blood flow, and increase lubrication.
Katie Fogarty26:31
And is this something that a patient is doing by themselves, or is this done under the guidance of a trained clinician?
Dr. Lynn Gray-Meltzer26:37
Both. We don't want to put up too many walls or barriers to access — wands and dilators are absolutely things you can purchase over the counter. They sell them at places like CVS and Walgreens now. They sell them online. But I will say many people get them and then are intimidated, even though they come with instructions. If they've never put something inside themselves, other than maybe a penis, it can be a little intimidating, and sometimes people are scared. So certainly, people have a better success rate in learning how to optimally use them, and use them progressively for the best results, when they are guided by a pelvic health therapist.
Katie Fogarty27:18
I want to move on now to talk a little bit about painful sex. I know we alluded to it when you were talking about what we can do to help relax and release, which allows us to have maybe a more comfortable, penetrative sexual experience. Women can have a range of different painful sexual moments — some of it's pelvic, some of it's insertion, some of it's vulvar. Walk us through what some of the common challenges are that women experience with penetrative sex, and what some of the solutions are that you recommend consistently.
Dr. Lynn Gray-Meltzer27:50
Low estrogen in midlife doesn't just affect the vaginal canal — it can also affect the hood of tissue around the clitoris, the external fascia around the skin at the vaginal opening, as well as the vaginal wall and the pelvic floor muscles. So sometimes women start to experience pain even with external stimulation, like rubbing the clitoris. Using increased lubrication on a finger before external touch can be very helpful, as well as applying a vibrating tool externally for a few minutes before any touch, as part of foreplay. The next thing, as you mentioned, can be insertional pain, or vestibular pain — like the opening to a doorway, that's the opening to the vagina. This is oftentimes multifactorial: there could be low lubrication, there could also be low elasticity, or lack of stretchiness, in the pelvic floor muscles, which is why stretching and prepping them can be so helpful. And then, also, some of the fascia that crisscrosses from the inner thighs, the buttocks, and the organs into the pelvic floor can be tight as well. So it's important not to rush things — oftentimes some prolonged foreplay can go a long way. Some of my patients teach a partner how to incorporate wands, dilators, and vibrators as part of foreplay, like a runner might foam roll or use a massage gun before running if they tend to be stiff early on — they can do some extra external massage, or massage right at the opening of the vagina, to make the tissue a little more soft and elastic. Also, open communication with a partner — if it's a male partner with a penis, telling him to go in just a little bit and then pause, do some of that pelvic balloon breathing imagery again, give the tissue a little time to stretch, maybe go in and out a little bit, then progressively insert a little more, a little slower — oftentimes leads to a much more comfortable experience. And then there can be pain with deep penetration. Oftentimes that's because a nerve, potentially the pudendal nerve, is entrapped in deep muscle knots or a tight ligament. I'd say that deep pain is where people most benefit from seeing a pelvic floor therapist who can do a detailed internal exam to problem-solve exactly what structure is tight internally and give them specialized treatment — both hands-on in the clinic, as well as teaching them how to use some of the wand tools to help loosen those deep muscle knots and entrapped nerves.
Katie Fogarty30:35
I want to walk through what women can expect from a pelvic floor appointment shortly, but before we do that, I want to take a minute to talk about pelvic organ prolapse. We are recording this conversation in June — it's coming out in June, which is Prolapse Awareness Month. Help us understand what pelvic organ prolapse means to a woman who's experiencing it, and is it preventable?
Dr. Lynn Gray-Meltzer31:00
So, pelvic organ prolapse is a lowering, or a hanging down, of one or more of the pelvic organs. You can have a urethrocele — that's when the urethra, or your pee tube, hangs a little bit low. You can have a cystocele — that's when the bladder hangs a little low, and maybe feels like pressure, or a little bulge, bubble, or egg in the front wall of the vagina. You can have uterine prolapse, that's when the base of the uterus is sliding down into the vaginal canal. Or you can have a rectocele — that's when the rectum, or where your poop is stored, is bulging almost like a little cul-de-sac, or pocket, into the back of the vagina. Sometimes even with the best preparation for birth, people do have a birth injury, which is one of the greatest risk factors for prolapse. But I will say that the severity can be reduced by pelvic floor rehab, and progression across the lifespan can absolutely be minimized with the correct intervention — that may be pelvic floor therapy, an internal brace called a pessary, or in some cases, surgery. But oftentimes, if conservative management is used early and often, unnecessary surgeries down the line can be prevented.
Katie Fogarty32:22
So if onset often occurs during birth due to a birth injury, is this something that can have onset in midlife, or is it something that normally, typically happens in your younger, earlier reproductive years?
Dr. Lynn Gray-Meltzer32:33
I'd say sometimes the wheels are set in motion in the younger years — so sometimes somebody, due to a birth injury, may have just a grade-one cystocele, their bladder is just sitting a little low, but it's really not at the point where it's very symptomatic or bothersome. But in midlife, with muscles being a little less robust, fascia maybe not being as supportive, as well as people being more prone to things like constipation and pelvic floor tightness — which can make it more likely that they're pushing and straining harder for a bowel movement — all those things can worsen or accelerate prolapse. So that's where we can really get ahead of things and teach better habits: lifestyle modification, how to push without straining, how to position yourself for gentle bowel movements, and how to maintain a healthy diet for a soft-but-formed stool consistency. All of these things help us get ahead of the problem and prevent worsening, symptomatic prolapse.
Katie Fogarty33:34
Well, I know that many women who listen to this show are very focused on fiber-maxing. For many years it was like, let's eat as much protein as we can — I think the word is getting out about the importance of fiber for our overall health. Obviously, that helps with things like constipation, makes stools softer. When we think about trying to avoid straining and pushing, where do you land on lifting heavy weights? Because sometimes with certain exercises or forms of exercise, there is pushing, there's straining, there's downward effort. Is that contraindicated if you have constipation, or if you're worried about something more serious, like organ prolapse?
Dr. Lynn Gray-Meltzer34:12
It's definitely not contraindicated to do heavy lifting, as long as you optimize your strategy. It's important how you do it — sometimes people go on a fitness craze, get very enthusiastic, and jump into very heavy lifting, and that's where they could make pelvic organ prolapse worse. However, if you work with a nutritionist or registered dietitian, work with a pelvic floor therapist, make sure you solve your constipation, and make sure your pelvic floor is ready and prepared to support your organs during lifting — and use strategies like exhaling through the effort of the lift instead of holding your breath — then you can absolutely, gradually build up to lifting heavy safely, which we want to encourage, because it's so important for maintaining muscle mass, bone density, hormone regulation, and good metabolism.
Katie Fogarty35:14
So we are recording this during June, as we said — we've all just learned that this is Prolapse Awareness Month — but June is also the kickoff to summer travel and fun, and I want to ask you about something that I read online. It said that your pelvic floor doesn't love vacation, and that made me stop in my tracks, because I love vacation, and I want to figure out what the link is between some pelvic floor issues that might crop up and what's happening during the summer months.
Dr. Lynn Gray-Meltzer35:41
Great question. A few things usually happen during travel that our pelvic floor doesn't love. One: if we're taking long road trips or long plane flights, oftentimes people start limiting fluids because they're worried about having to stop too frequently to pee.
Katie Fogarty36:01
I knew you were following me around, Lynn. I'm telling you, this is —
Dr. Lynn Gray-Meltzer36:05
So when we limit water, a few things can happen. One, our body needs to hold on to that water, so less is available to move through the walls of our intestine and mix with our waste, food, and fiber — so our poops can get harder and drier instead of soft but formed. Also, sometimes we exacerbate the issue because our urine gets more concentrated and irritates the bladder lining, so sometimes we feel like we need to pee even more frequently and urgently, and then people start restricting fluids even more. The other thing is that our bowels are creatures of habit, so even if you're having a fun, carefree vacation and you don't feel stressed, just the fact that you're waking up in a different environment, eating at slightly different times, and having more variable access to a familiar bathroom can make our bowels go into a bit of a freeze, hold, and store response — and we may not get that robust urge, or what's technically called the "call to stool," as reliably. The third thing is, of course, with vacation, sometimes we're not getting the same amount of fruits and vegetables — both soluble and insoluble fiber from those fresh leafy greens and things like that help give our stool that just-right consistency. We may be eating more easy-to-grab, on-the-go things.
Katie Fogarty37:31
So what are some travel hacks to make sure that we can wake our bowels up, make sure that things run smoothly, and that we can feel great while we're out and about trying to enjoy ourselves?
Dr. Lynn Gray-Meltzer37:42
Number one is hydration. Don't restrict your water intake, and make sure it is water — if you're drinking things like sodas or coffee, those don't really count toward your overall water intake, even though they're liquid; you basically need to subtract them out. So, just pure water. That's why you want to learn and practice those urge-deferral strategies, so that you can take that long flight but keep hydrating well without worrying about when you're going to need to get up. The next thing is, ideally, you're going to bring some high-fiber snacks with you — that could be something like dried prunes, some high-fiber bars to have as snacks maybe instead of grabbing a pastry. And then the other thing is: try not to skip meals, and focus on high-quality fiber and protein. And then, finally, even if you're using all different toilets, and maybe you don't have access to something like a toilet stool that can put you in a more optimal, semi-squatting position, you can still do your best to position well. You want to have your feet on the ground — no sitting way back on the toilet, and no hovering. So, feet on the ground, bum on the toilet — put some strips of toilet paper down on the seat if you need to. Then you want wide knees, straight back, and then hip-hinge forward, and rest your elbows or forearms on your knees, so you're essentially getting into a squatting position, but you're sitting on the toilet. This allows the rectum to straighten and our pelvic floor to relax, so that with a few deep breaths and just a gentle push that you're breathing through — not holding your breath — that poop is more likely to be able to slide out, instead of feeling stuck at the outlet.
Katie Fogarty39:30
And are there exercises that one can do, beyond the ones that you've already outlined, that can help train our system to relax? Are there breathing exercises? Are there certain stretches that we can be doing that help with this?
Dr. Lynn Gray-Meltzer39:42
Yes, so the pelvic floor has a lot of neighbors that can either be friendly neighbors that help it out, or can make the pelvic floor aggravated. Even though muscles have a start and end point, fascia, or connective tissue, flows between groups of muscles — so the inner thighs (called your adductors), your hip flexors, and the buttocks muscles share a lot of fascia that flows into and crisscrosses the pelvic floor. So stretching the inner thighs, like a butterfly position — lying on your back, where the soles of your feet are together and your legs are flopped to the side — hip flexor stretching, so that could be lying on your bed with one leg hanging off, opening the front of your hip, or a half-kneeling position, where you're lunging forward, again opening the front of your hip. Or anything that stretches the buttocks area, like a child's pose, a happy baby pose, or a figure-four position, where you're crossing an ankle over the opposite bent knee and then pulling your thigh to your chest. Any of those stretches for the surrounding muscle groups — where you're hanging out there, relaxing for 30 seconds, doing that deep pelvic floor balloon breathing — is going to make those muscle groups friendly neighbors that help the pelvic floor release.
Katie Fogarty41:06
I love this idea of friendly neighbors. I'm going to work on all of it — I do some of those already, but haven't done them with an eye toward making things work smoothly, particularly with things like travel, because we all experience that. So those are great tips.
Dr. Lynn Gray-Meltzer41:19
You want to be doing them for long enough to get a muscle and fascia to actually creep, release, and lengthen — you need about 30 seconds to a minute, minimum. So you want to just chill in that position, mid-range — gentle stretching wins here, faster and harder is not better. And while you're in that position, you can be doing that pelvic balloon breathing, or on every inhale, imagine a rose blooming open, widening your anus and vagina. But definitely make sure you're holding them long enough to be effective.
Katie Fogarty41:55
All right, well, we're hanging out with our friendly neighbors for at least a minute stretch — that's terrific advice. Okay, final question for you: walk us through what happens during a pelvic floor PT appointment. What should a woman expect? What if they feel a little bit nervous or unsure? What happens during, like, the first visit and subsequent visits? Put it on our radar.
Dr. Lynn Gray-Meltzer42:15
Sure. So the first visit will take a thorough history. We don't want to know just about your pelvic floor, bowel, bladder, and pain symptoms — we also want to know what stress is like in your life, what your sleep quality is, what your nervous system is up to. We want to know about any injury history — again, not just in the pelvic floor, not just to do with birth if you've given birth before, but also any back, tailbone, or hip injuries. And then we also want to know about some of those habits we talked about: what's your hydration like, what's your diet like. Then we want to know your goals — what's meaningful to you, what's bringing you in — and that could be short-term goals. Sometimes there's an immediate pain issue, like painful intercourse, but then we also want to know longer-term goals — maybe it's somebody who hasn't run or hiked for years, or is now caring for a grandkid — sometimes there are longer-term goals that people didn't even think were possible, and we want to help lay out a roadmap. So once we have a little more information about history, symptoms, and goals, we'll lay out what we want to examine and why. Usually that involves doing a bit of a whole-body screen — sometimes we call it a posture assessment or a functional movement assessment — and then, usually, using a picture or model, before we even get started, we'll talk you through the different structures of the pelvic floor, explain what might be going on based on the symptoms you've shared, and how we'd like to look at them now. When we get to the actual exam, usually what people are most nervous about is the pelvic part. So I always tell people there are three levels we could go to, and any of them are fine — it's always the person's choice. The least invasive is that we check bony landmarks, meaning sort of the shape and alignment of the pelvis, over clothes, and with a gloved hand, but over clothes, palpate — meaning feel — at least the perineum area. That's where all the pelvic floor muscles crisscross, it's like the little bridge of tissue between the vagina and anus, and even over clothes we can get a sense of whether it's soft and spongy or tight and hard, and we can at least screen if the woman is able to relax and contract, bear down, take a deep breath, relax, and release. The next level would be that the healthcare provider steps out of the room and gives the patient a sheet and asks her to undress below the waist. Then, when she's ready, the practitioner comes back in, washes hands, gloves up, and does an external — meaning outside the body — pelvic floor exam, just on the skin, and that's where we can get a little more detailed, getting right on some of the different structures, like the ligaments and different specific muscles, from the outside, and get a better sense of the motor control — what the timing and coordination of contraction is like — by having the person mimic, say, a cough. The third level is an internal exam, so we switch our gloves, sanitize our hands, put on fresh gloves, lubricate a finger well, and then, either through the anus and rectum or through the vagina, depending on the person's preference or particular situation — because those internal tubes are stretchy, we can gently press on those internal walls and feel the deep layer of the pelvic floor muscles — and that's where we can get the most detail about giving a strength grade, feeling nerve pathways, and getting the most detailed information, so we can build a customized intervention plan to help them feel well again.
Katie Fogarty45:46
Thank you for this fantastic overview. It's so clear, and I just want to share with listeners that I did 10 rounds of pelvic floor therapy years ago to deal with some bladder leaks, and I can 10-out-of-10 recommend it. It truly made a difference. The woman I worked with was incredible — she was very supportive, and while I was a little anxious going into it, it was super worthwhile and comfortable when you're in the hands of a talented, supportive practitioner. Lynn, thank you so much for this masterclass in pelvic floor therapy today. I truly appreciate your time. I would love for you to share with our listeners where they can follow you and find out more about your work before I say goodbye.
Dr. Lynn Gray-Meltzer46:26
Well, for June, since it's Pelvic Organ Prolapse Awareness Month, I'm posting pelvic organ prolapse facts and management tips every day on our Instagram account, so you can look up Weeks Wellness on Instagram. Also, you can go to weekswellness.com if you're ever looking for more links to videos and tips, and if you ever want to send us a question, you can message us and we'll get back to you with more information.
Katie Fogarty46:59
Lynn, thank you so much again for your time today.
Dr. Lynn Gray-Meltzer47:01
My pleasure. Thanks for having me.
Katie Fogarty47:04
This wraps A Certain Age, a show for women who are aging without apology. Lynn is incredible at describing complicated medical issues, physiology, and biology in really simple, visual terms. I took so much away from this episode — I hope you did as well. Please let me know what you learned in an Apple Podcasts or Spotify review. Please share this show with the women in your life — I am not kidding, millions and millions of women suffer needlessly. We need to get the word out about pelvic floor therapy, because here's what you might not know: in France, every single woman gets 12 sessions of pelvic floor therapy when they have a baby. That doesn't happen in the US, and years later we pay the price. So, I've learned a lot — I hope you did too. I'm going to link out to all the references that Lynn mentioned in the show notes — hop on over to CertainAgePod.com to check those out. Thanks for sticking around to the end of the show. And, as always, special thanks to Michael Mancini, who composed and produced our theme music. See you next time, and until then — age boldly, beauties.