The Wisdom of Menopause

by Christiane Northrup

  As with most exercises, there’s a right way and a wrong way to do squats, and even doing them the right way often requires working up over time to a proper full squat. Bowman’s “Down There” for Women DVD in her Aligned and Well series presents a step-by-step guide to a safe and effective squat program, offering a progression that will gradually get you where you want to be. For a brief look at the squat exercises, including photographs of proper form, check out “You Don’t Know Squat” from Bowman’s Katy Says blog (www.katysays.com/2010/06/02/you-dont-know-squat).

  But remember, Bowman doesn’t trash Kegels completely. She stresses that proper pelvic health and alignment requires maintaining balance. If you work only your glutes and don’t ever do any Kegel squeezes, your pelvic floor muscles will be long but not strong, and you still won’t get the support you need. Even so, Bowman insists that you don’t need to do the hundreds of Kegels a day that the experts have been recommending. To keep your pelvic muscles balanced while you do Kegels (so you won’t reverse the proper alignment you’ll be trying to establish with the squat program), she suggests doing Kegels in a proper squat position (as detailed in her program), gently tensing and fully releasing the pelvic floor muscles ten times.

  The release is a vital part of doing Kegels, she stresses, suggesting you relax your pelvic floor muscles just shy of urinating for this stage. Otherwise, your pelvic floor muscles won’t completely lengthen out and instead will stay short and tight, continuing to contribute to pelvic health problems.

  Supporting healthy pelvic alignment also requires paying attention to the way you hold your body, especially your pelvis. Wearing high heels, for example, can contribute to pelvic floor dysfunction if this causes you to tilt your pelvis for balance (although wearing heels occasionally doesn’t cause much harm). If you’re what Bowman calls a “tucker,” someone who sucks in your gut and pulls in your backside, you’re pulling your tailbone out of alignment and weakening your pelvic floor. So forget what your mother told you about not sticking your butt out! Women also tend to sit in this tucked position, Bowman notes. When you’ll be sitting for more than two hours at a time, she suggests sitting on a rolled towel and tilting your hip bones forward just enough to establish a healthy lumbar curve in the small of your back. (This is also a good position for doing Kegels, she says.)

  Many women are able to improve pelvic muscle tone, enhance sexual pleasure, and resolve or greatly improve their incontinence by strengthening the muscles of the pelvic floor and urethra. A strong pelvic floor can withstand increases in intra-abdominal pressure without giving out and also increases blood flow and innervation of the pelvic organs. That is exactly what Arnold Kegel, M.D., had in mind in 1948 when he told his patients to practice vaginal contractions in preparation for childbirth. Ideally, every pregnant woman should be doing Kegels regularly both before and after birth so that these muscles will be strong enough to withstand the rigors of labor and delivery. When Kegel exercises are done properly and consistently, they work very well. Kegel exercises actually condition the pubococcygeus (PC) muscle for sexual arousal. They also increase the flow of blood to the genitals, which enhances the ability to reach orgasm and also improves vaginal lubrication. Some studies report that up to 75 percent of women are able to overcome stress incontinence with Kegels alone.23

  But again, doing Kegels effectively means both keeping your pelvis untucked and concentrating on developing strong glutes by doing squats three times a day. Unfortunately, the vast majority of women who are told to do Kegel exercises have not been instructed in how to do them properly and also give up too soon—which is why so many women think they don’t work and why the reported results are so variable. Many women prefer using weighted vaginal cones or jade eggs as an alternative way to get the same benefits as Kegels (see below).

  DEVELOP LIFETIME PELVIC POWER BY STRENGTHENING

  YOUR PC MUSCLE (KEGEL EXERCISES)

  1. Identify the PC muscle. Sit on the toilet with your legs spread apart. See if you can stop the stream of urine without moving your legs, your abdomen, or your buttocks muscles. The muscle used to stop the flow of urine is the PC muscle. This is the only muscle that should be contracting. Your PC muscle will not become stronger if you contract your abdominal, thigh, or buttocks muscles at the same time that you are doing a PC contraction. Check yourself by inserting two fingers in your vagina while contracting. You will feel the muscle tighten around your fingers.

  2. Learn the exercises.

  Slow clenches. Squeeze your PC muscle and hold it clenched for a slow count of three. Work up to a slow count of ten after a couple of weeks or so. Though it’s not necessary to hold your breath while counting, it may be helpful at first to establish your concentration. Release and exhale.

  Quick contractions or flutters. Now contract your PC muscle quickly, once per second.

  Push-outs. Clench your PC muscle and then push out as though you are bearing down to move your bowels. Hold for a count of three to ten. Note that your abdominals will contract when you do a push-out. Your anus will also contract.

  3. Train your PC muscle gradually. Begin with ten slow clenches, ten flutters, and ten push-outs (one set) three to five times every day. After one week, add five slow clenches, five flutters, and five push-outs to the original ten. That’s a total of fifteen reps for each set. Continue to do three to five sets a day. Next add five of these the following week, so a set equals twenty reps.

  Continue doing three to five sets per day to maintain optimal pelvic tone, urinary continence, and sexual function. In as little as a week’s time you will definitely notice a difference in your ability to strengthen these muscles—if, that is, you are using the proper form by keeping your tailbone untucked and you’re also strengthening your glutes. It may take three to four weeks to notice a change in urinary symptoms. You will probably notice a change in sexual responsiveness in a couple of weeks if you do both Kegels and glutes properly. Note: You can do Kegels anywhere and anytime: driving, watching TV, cooking, sitting in the bathtub—even riding the ski lift.

  When you start training your PC muscle, you’ll probably find that it doesn’t want to stay contracted for the entire count of ten. It may also be difficult to do the flutters. That’s because the muscle is weak. Don’t worry about it. Take a rest during a set if needed. But be persistent. Like all muscles, the PC responds beautifully to resistance training. You’ll be amazed by how fast you’ll get results if you stick with it. Also, every time you do the exercises, you’ll be giving yourself a powerful reminder that you have the strength and stamina to create and maintain healthy boundaries. (All this while also enhancing your sex life—what could be better?)

  There’s another way to do Kegels that doesn’t require counting to ten or focusing on which muscles to contract. In this method, which is based on ancient Chinese techniques, you insert a weighted cone or a jade egg into your vagina and simply hold it in place for at least five minutes twice a day, gradually working up to fifteen minutes twice a day. You start with the heaviest cone that you can easily hold in for one minute, gradually move on to the heavier cones, and finally shift to a maintenance program. (Cones range in weight from 15 to 100 g.) Holding the cone in the vagina automatically uses just the right muscles. I have been recommending these cones for years and my patients have had excellent results with them, provided there are no complicating factors such as infection, neurological damage, or use of diuretic medications or caffeine. About 70 percent of women can expect improvement or cure within four to six weeks of consistent use.24 (See Resources.) I also recommend the Kegel-Master 2000 (www.kegeltoner.com), which provides fifteen adjustable resistance levels, as well as the FPT (Feminine Personal Trainer), a highly effective stainless-steel vaginal weight that strengthens the pelvic floor through resistance training in ten-minute sessions (available from As We Change, 800-203-5584 or www.aswechange.com). There are also an entire series of exercises available using jade eggs. These exercises are very effective in helping create v
aginal dexterity and enhanced erotic potential (see www.thedesiletsmethod.com).

  URINARY HEALTH

  At midlife, the loss of hormonal support in the vagina and lower urinary tract is often accompanied by the loss of muscle tone in the pelvic floor. As a result, many women experience urinary problems, ranging from loss of urine when coughing or sneezing to recurrent urinary tract infections, and uterine prolapse (a condition with a hereditary component that is often exacerbated during midlife). The number of women suffering from these disorders is rising rapidly. Experts estimate that by 2050, one in three women will have some form of pelvic floor disorder. The number of women with urinary incontinence is projected to increase by 55 percent (from 18.3 million in 2010 to 28.4 million in 2050), while the number with pelvic organ prolapse is estimated to jump by 46 percent.25

  Keeping Dry: Maintaining or

  Regaining Bladder Control

  Urinary incontinence, the involuntary leakage of urine, is a major health problem that affects approximately thirteen million people in the United States. Though 10 to 30 percent of women age fifteen to sixty-four experience urinary incontinence at least some of the time, the condition tends to increase in frequency with age. It often makes itself known during perimenopause, when a great deal can be done to make sure it doesn’t progress. By the time women reach age sixty-five and over, the overall rate of incontinence increases to about 15 to 35 percent.26

  Though the problem does affect men, it affects women five times as often. Many women feel too embarrassed to bring it up with their doctors and therefore don’t know about many of the new and effective treatments that are available. To compound the problem, many physicians aren’t up on the latest treatments, either. In an editorial in the Journal of the American Medical Association, Neil M. Resnick, M.D., wrote, “Most physicians have received little education about incontinence, fail to screen for it, and view the likelihood of success as low.”27

  This doesn’t mean that you should suffer in silence. Urinary incontinence is easily diagnosed and often treatable with excellent results. Read through the treatment options outlined below and see which ones speak to you. Then discuss them with your health care practitioner. If possible, seek out someone who specializes in the evaluation of female urological problems. Determining exactly what type of incontinence you have will allow you and your provider to create an individualized plan of action. Many gynecologists are now trained in urogynecology and routinely do this evaluation in their offices.

  Stress urinary incontinence (SUI) is the most common type of incontinence. It is diagnosed when a woman loses urine while performing any activity (such as laughing, standing up quickly, or exercising) that increases her intra-abdominal pressure and thus overrides the ability of her urethral sphincter to stay closed. This may result from problems with the sphincter muscle itself or from the fact that the angle of the urethral tube has changed, becoming too mobile to function properly—a condition known as urethral hypermobility. A number of factors that are increasingly common in perimenopause lead to the following situations.

  ~ Weakened pelvic floor muscles. Unless you work out regularly and include your pelvic floor muscles, then these muscles, like your biceps, may be weaker than they should be.

  ~ Thinning of the tissue of the outer urethral area, from estrogen deficiency.

  ~ Nerve damage resulting from childbirth, major pelvic surgeries, a history of radiation, smoking, or excess intra-abdominal fat that pushes the urethra out of the proper position every time you urinate. Innervation of the urethral sphincter also tends to decrease with age, but age alone does not inevitably lead to loss of function. (Research has shown that nerve density in this area varies widely in perimenopausal women.)28

  ~ Underlying neurological disorders such as multiple sclerosis can result in other types of incontinence.

  Whatever the exact cause of your problem, there are a lot of solutions besides spending the rest of your life wearing adult diapers!

  Nonsurgical Incontinence Solutions

  ~ KEEP A RECORD. Keeping a record will help both you and your health care practitioner learn which substances and situations may be contributing to your incontinence. Record how often you experience the problem, any activity that precedes it, how much urine actually leaks, whether or not you experience a warning beforehand, if it wakes you up at night, and whether it follows the ingestion of certain foods, drinks, or medications. Sometimes you can alleviate your problem just by becoming aware of when it happens and making adjustments.

  Many women also have an increased urinary output on the first dady of their period, when they get rid of all that premenstrual fluid. On these days, stress incontinence will always seem worse because your bladder fills more quickly.

  ~ REDUCE OR ELIMINATE CAFFEINATED DRINKS. Many women have stress incontinence only when urine output is increased from drinking coffee or tea. Even decaf coffee is a diuretic—and so is cold weather (I never drink a cup of coffee in the morning if I’m going skiing, otherwise I’ll have to stop at the lodge after every other run). Coffee is also a known bladder irritant. I’ve been able to help some women resolve their incontinence problem completely just by providing them with this information.

  ~ MEDICATION. Since there is a great deal of overlap between pure urinary stress incontinence and urge incontinence, many women are also offered medication to relax the bladder muscle regardless of what type of incontinence they have. (See section on urge incontinence.)

  ~ CONSIDER ESTROGEN CREAM. The outer third of the urethra is estrogen-sensitive, just as is the vaginal tissue. In post- or perimenopausal women with stress urinary incontinence, estrogen cream placed on the top surface of the outer third of the vagina has been shown to enhance nerve function and blood supply to the urethra, which in turn increases muscle size and strength. About 50 percent of women who have incontinence associated with estrogen depletion will be cured or greatly improved simply by re-estrogenizing their urethral area. This success rate increases for women who strengthen their pelvic floor simultaneously.

  While systemic HT also works to relieve urinary symptoms, I recommend estriol vaginal cream for this purpose. It is extremely effective when applied locally, and it doesn’t result in any appreciable absorption into the bloodstream. That makes it ideal for any woman who is worried about the risks of estrogen, including those with a history of or risk factors for breast cancer. Estriol vaginal cream is available by prescription from any formulary pharmacy that carries natural hormones. The usual strength is 0.5 mg/g. (Interestingly, the Women’s Health Initiative study showed that women on Premarin or Prempro actually had an increase in stress urinary incontinence. This is confusing given the support that estrogen can provide for pelvic structures. If you use systemic estrogen of any type, I recommend choosing other forms besides Premarin or Prempro.)

  ~ STRENGTHEN YOUR PELVIC FLOOR. See the Master Program for Creating Pelvic Health, earlier in this chapter.

  ~ HIGH-TECH PELVIC FLOOR REHAB (BIOFEEDBACK AND EMRT). Biofeedback-assisted behavioral treatment provides immediate audio and visual feedback to reinforce your control of your pelvic muscles. It has shown excellent results, ranging from 50 percent to 89 percent improvement after six to eight weeks. It has been shown to be far more effective for incontinence than medication, and it is generally available from physical therapists specially trained in the technique.29 The disadvantage is that it requires the use of rectal or vaginal probes.

  ~ URETHRAL INSERT. FemSoft (from Rochester Medical) is a soft silicone tube with a balloonlike tip at one end and a flange at the other end. A sheath filled with mineral oil encases the tube. Using an applicator, you insert FemSoft into the bladder. The mineral oil in the tube flows into the balloon tip, which conforms to the shape of your bladder and creates a seal around your bladder neck, preventing leakage. To urinate, you pull the device out by grasping the flange end, which remains on the outside of your urethra. After voiding, you insert a new device. Available by prescription. (For information,
call 800-336-7638 or visit www.tryfemsoft.com.)

  ~ URETHRAL PROSTHESES. Urethral prosthetic devices are very useful for stress incontinence caused by urethral hypermobility, a condition in which the angle of the urethral tube has changed, becoming too mobile to function properly. These devices work by stabilizing the bladder base and reestablishing a normal angle between the bladder and urethra. (You may have noticed that it’s more difficult to urinate with a tampon in. This is because the tampon elevates the bladder neck. A diaphragm can do the same thing.) Urethral prostheses are virtually risk-free and can be used on an as-needed basis, making them especially good for those women who have incontinence only during specific activities such as golf or aerobics. They can also be used temporarily while you’re strengthening your pelvic floor muscles. Available products include the Incontinence Ring, Incontinence Dish, and Incontinence Dish with Support (all from Milex). Many users of these devices report a heightened sense of self-confidence and freedom.

  ~ MAINTAIN OPTIMAL VITAMIN D LEVELS. See the Master Program for Creating Pelvic Health, earlier in this chapter.

  Surgical Techniques to Relieve Bladder Symptoms