The Wisdom of Menopause
Page 38
If you’ve strengthened your PC muscle maximally and still have incontinence problems, then a surgical solution may help.
~ STANDARD SURGICAL REPOSITIONING PROCEDURES. There are a variety of tried-and-true surgical techniques for treating stress urinary incontinence that give long-term success rates of 80 to 95 percent in the hands of an experienced surgeon. In all of these procedures, sutures are placed in the tissue near the urethra to elevate the bladder neck so that it functions properly. The disadvantage of these approaches is that they require an abdominal incision and a fairly long recovery period.30
~ MINIMALLY INVASIVE REPOSITIONING PROCEDURES. A whole host of new surgical techniques have recently been developed to help permanently reposition the bladder neck so that urethral function is restored. They are done laparoscopically on an outpatient basis. Short-term results with the new techniques are also favorable, with a cure rate of about 82 percent. Long-term results are not yet available.31 In addition, several surgical techniques are now available to suspend the uterus, including laparoscopic suspension—thus “curing” prolapse without removing the uterus. Results have been mixed so far.32
~ INJECTABLES. A variety of agents, including body fat or bovine collagen, can be injected around the urethra under local anesthesia. These injections increase the volume of urethral tissue, allowing it to close properly and prevent the passage of urine during times of increased intra-abdominal pressure such as coughing, laughing, or changing position. They are effective immediately and can be done as an office procedure. A skin test is necessary four weeks prior to the procedure to be certain that there will be no allergic reaction to the material. It usually takes two or three injections over time to get the desired result, and they may eventually have to be repeated. The improvement or cure rate ranges from 82 to 96 percent, depending upon the type of incontinence being treated.33
~ ADJUSTABLE CONTINENCE THERAPY (ACT). This minimally invasive surgical procedure for urinary stress incontinence involves implanting two silicone balloons on either side of the urethra at the bladder neck. The balloons are then filled with saline, which compresses the urethra, preventing leaking. The amount of saline in the balloons can be adjusted after they’re implanted via a port placed under the skin in the labia. Initially developed in the United States but currently marketed only in France, the device has not had the success rate of other therapies and review studies suggest it be considered only as a last resort.34 New clinical trials in the United States are currently testing what researchers hope will turn out to be a more effective version. (See www.uromedica-inc.com.)
~ STEM CELL THERAPY. This is one of the most promising new procedures for stress urinary incontinence, and clinical trials are currently being conducted at the University of Toronto, the University of Pittsburgh, and Vanderbilt University Medical Center in Nashville. In this therapy, doctors take cells from the patient’s thigh muscle during a needle biopsy procedure. The cells are then sent to a lab, where they are refined and grown into stem cells. Four to six weeks later, the doctor injects the stem cells into the bladder’s sphincter. These cells then help to strengthen the muscles that control voiding. Both procedures—the biopsy and the injection—each take half an hour or less and are done on an outpatient basis. Preliminary data from a small one-year follow-up study (the first conducted in North America) showed improvements in five of eight women, with one achieving complete bladder control. The improvement started between three and eight months after the injections, with no serious side effects.35 Stay tuned for more news on this promising procedure.
Irritable Bladder: Urge Incontinence
Some incontinence is caused by involuntary contractions of the bladder muscle (the detrusor muscle). These involuntary contractions cause strong, sudden urges to urinate and the feeling that you might be about to wet yourself—which sometimes happens. Women with an overactive bladder often find themselves missing out on normal activities because they have to go to the bathroom so often and worry whether or not one will be available.
Urge incontinence is commonly treated with drugs such as tolterodine (Detrol), which inhibit detrusor contractions. Side effects include headache, dry mouth, dry eyes, constipation, and indigestion. Another drug called oxybutynin is also useful. It’s available by prescription as Oxytrol (a transdermal patch) and Gelnique (a transdermal gel). Though this type of medication can be very helpful, there are other options.
Sometimes bladder irritation is caused by the localized lack of estrogen in the bladder and urethral area associated with perimenopause and menopause. The problem resolves with local or systemic estrogen therapy. Caffeine is also a bladder irritant. As little as one cup of coffee per day can result in bladder symptoms.
Sacral nerve stimulation (first offered with InterStim from Medtronic; see www.interstim.com) became available for women with urge incontinence in the late 1990s. This pacemaker-like device is surgically implanted just below the skin’s surface on the lower back. It then delivers mild electrical impulses to the sacral nerves, which influence bladder function and improve control.
A newer technique called percutaneous tibial nerve stimulation (PTNS) is a less invasive version of sacral nerve stimulation and was inspired by acupuncture. PTNS involves having a doctor insert a thin, needle-like electrode into the ankle to deliver a low-frequency current to the tibial nerve, which is connected to the sacral nerves, which in turn regulate bladder contractions. Each treatment lasts about a half hour and, like acupuncture, is basically painless. Patients return once a week for about three months and can have more treatments later if they are needed. Researchers report a 60 to 80 percent positive response rate.36
Injecting botulinum-A toxin (commonly known as Botox) into the bladder and the bladder’s sensory pathways is currently being evaluated for treating urge incontinence. Studies show that repeat injections (probably three to nine months after the initial treatment) would be necessary as the Botox wears off, but more worrisome is the complication of urine retention in many women.37 The Mayo Clinic is conducting trials that involve injecting a solution containing Botox and dimethyl sulfoxide (currently FDA-approved only for interstitial cystitis) into the bladder with good results and no side effects.38
Irritable bladder syndrome can also be associated with stressful psychological situations such as taking an exam, being evaluated at work, or worrying about some aspect of your life that isn’t working. Many perimenopausal women find that they repeatedly have to get up at night to urinate when their sleep is interrupted by chronic worry or anxiety. In my experience, there is an exquisite connection between the worry-and-obsess area of the brain and the bladder. Happily, we each have the ability to interact consciously with this area and get it to cooperate with us.
Biofeedback-assisted behavioral training, for example, has been shown to reduce involuntary incontinence episodes by about 80 percent (drug therapy results in a 68 percent reduction).39 In one controlled study, women were asked to keep a voiding diary in which they recorded the time of day of the urgency and what they were doing at that time, so that their voiding patterns and the circumstances surrounding them would become clear. They were then shown how to identify their pelvic muscles and contract and relax them voluntarily while keeping abdominal muscles relaxed (the same as with Kegels)—a procedure that took only one session. Next, the women were taught to respond to the sensation of urgency by pausing, sitting down if possible, relaxing their entire body, and then contracting their pelvic muscles repeatedly to diminish urgency, inhibit detrusor muscle sensation, and prevent urine loss. When the urgency subsided, they proceeded to the toilet at a normal pace. Women were encouraged to practice pelvic muscle contraction at home in various positions and also during activities when urge incontinence is most apt to occur. Finally, they were taught to practice interrupting or slowing their urine stream during voiding once per day.
I strongly recommend that women with incontinence problems (who have faithfully strengthened their pelvic floor and brought aware
ness to the area in the ways I’ve described above) consult a gynecologic urologist, a relatively new type of specialist. Doctors trained in this area are the best resources to discuss both medical and surgical options for women with bladder problems of any kind.
LIANA: Addressing Long-Standing Urinary Health Issues
My friend Liana’s story is a great example of how successful treatments for urinary incontinence can be when combined with a few additional techniques to create an entire mind-body approach. Liana’s issues with urinary health stretch back to the second grade, when she had recurring urinary tract infections caused by her refusal to use the bathroom at school. (The school had taken the locks off the stall doors, and she was so afraid someone would walk in on her that she just held it until she got home.) She was even hospitalized once for a special test that involved being catheterized. “What I remember most about that was how badly it burned to urinate after having the catheter in me,” she remembers.
Liana’s problems worsened after she gave birth at age forty and ended up with a severely prolapsed bladder, which caused her to leak urine constantly. A surgical procedure she hoped would help actually ended up backfiring, leaving her with incontinence and chronic pelvic pain.
Not surprisingly, her sex life had pretty much fizzled out, but she certainly wasn’t ready to give up. “After seven years of chronic pelvic pain,” she told me, “I began studying sacred sexual practices in hopes that I might somehow find a way to feel sexually intact and whole again. But within a month, I began experiencing a searing hot pain deep inside my pelvis. It felt like someone was stabbing me with a red-hot sword. Sometimes the pain was so intense that I would be incapacitated for hours at a time, although my doctor couldn’t find anything wrong. It was a mystery.”
I recommended that she have her bladder repaired by a urogynecologist and also that she work with Doris Cohen, Ph.D., a clinical psychotherapist, medical intuitive, and healer who is the author of Repetition: Past Lives, Life, and Rebirth (Hay House, 2008). Here is Liana’s account of what happened:
Dr. Cohen’s guides linked my current pelvic pain to a past life in which I was three years old when my mother died in childbirth. My name had been Amelia then. We were a pioneering family living far from anyone, and my father was so distraught by my mother’s death that he lost his mind and began abusing me nightly with a hot fireplace poker. As soon as Dr. Cohen gave me this information my entire body began shaking. I knew it was true! The guides told me that Amelia’s trauma was being repeated in my body in this lifetime. In order to heal my pelvis, Dr. Cohen said, I needed to go back to the lifetime when the wounding happened.
She gave me an exercise to do for forty days to release this pattern of repetition. Each day I was to take four deep breaths and imagine a magical garden. In the garden is a body of calm water, trees, flowers, butterflies, angels—and Amelia, at whatever age she chose to be. I was to enter the garden as the adult Liana and reassure and comfort Amelia, telling her that the garden was a safe place filled with angels who would take care of her. Then I was to say goodbye to Amelia and come back into the present as my adult self. When I first started this exercise, Amelia showed up as a young woman. But each day that I went to the garden, Amelia became younger and younger until finally she was four years old.
In the meantime, I found a urogynecologist who agreed to do my bladder repair surgery. During one of the presurgery tests, a nurse practitioner inserted a catheter in my urethra and electrodes in my vagina. Even though I wasn’t either frightened or cold, my legs began to shake uncontrollably. I knew instantly that little Amelia had been activated, so I closed my eyes, breathed deeply, and went to meet her in the garden. I found her running around like a wild animal, trying to pull her hair out and screaming, “Stop! Make them stop!” She wouldn’t let me get near her, so I called on the angels in the garden to help. Suddenly a natural hot springs appeared, and the angels coaxed Amelia to get into the hot water. They began brushing her hair to soothe her, and she finally began to relax. The moment she began to calm down, my legs stopped shaking! I left Amelia with the angels and came back to the present moment, completing the testing with no discomfort.
I continued to do the Magic Garden exercise as I prepared for the surgery, and I also used Belleruth Naparstek’s CD for successful surgery (A Meditation to Promote Successful Surgery; see www.healthjourneys.com). The results were astounding! I was awake and able to urinate without pain within a few hours. My healing was swift and relatively pain free. And best of all, one year later I am still 100 percent continent and have had zero pelvic pain. None! I am sexually intact and am able to enjoy physical intimacy with my husband with no pain!
Liana’s story illustrates how multifaceted and mysterious the healing process can be. Past-life influences on health are, in my view, both real and important. The research of Brian L. Weiss, M.D., a prominent psychiatrist and the author of Many Lives, Many Masters (Simon & Schuster, 1988), bears this out. So does the work of many others, including the famous Edgar Cayce.
For more information about urinary incontinence, contact either the National Association for Continence at 800-252-3337, www.nafc.org, or the Simon Foundation for Continence, 800-237-4666, 847-864-3913, www.simonfoundation.org.
Recurrent Urinary Tract Infections
Urinary urgency and frequency are often the result of recurrent urinary tract infections. Get a medical evaluation to be sure that you don’t have some anatomical problem that is contributing to your infections. Make sure that the outer third of your urethra is well estrogenized. Your doctor should be able to evaluate this during a pelvic exam, because the urethra runs right under the top part of the vagina and is easily felt and observed. If there is any evidence of thinning of the outer urethra, get a prescription for estrogen cream. Low-dose Premarin vaginal cream used twice weekly has shown good results with no endometrial problems.40 (See MEDICATION.)
Also follow the food and supplement plan as well as the advice on acupuncture and Chinese herbs outlined in the Master Program for Creating Pelvic Health, earlier in this chapter.
There you have it. I hope this information has given you hope and let you know how much can be done to improve all aspects of your urinary and pelvic health. Don’t resign yourself to using adult diapers the rest of your life when so many other solutions are available. You are not alone—incontinence is more common than diabetes. It is also often easier to treat! But you have to take the first step. Ask for help.
9
Sex and Menopause:
Myths and Reality
It’s no secret that many women experience a decrease in their sex drive during perimenopause. What’s not so obvious is the wisdom behind this decrease—which, by the way, doesn’t have to last forever. As previously discussed, perimenopause puts all your relationships, including the one you have with yourself, under a microscope. This transition forces us to reevaluate every aspect of our relationships and update them. And this includes our sexual relationships.
Libido at perimenopause can be likened to sap in a tree. In the fall and winter, that sap goes deep into the roots of the tree, where it lies waiting for the inevitable rise and new growth that begin in the spring. During the winter, there are no leaves on the tree and it may seem as though nothing much is happening. But deep inside, the tree is undergoing rest and renewal before another cycle of growth. In many women, libido turns inward to nourish the new growth that is under way on a soul level but which cannot yet be seen on the outside. Here’s what that means: if a woman’s sexual relationship needs to be updated, if she is not getting the tenderness and care she desires, or if she has unfinished business with her mate, then any or all of these issues may well arise during this time.
This change in sex drive often has absolutely nothing to do with hormone levels and everything to do with a woman’s deepest unfilled desires, desires that are now rising into her consciousness. The heart in our chest is the high heart, and the uterus and genitals are the low heart. The high he
art and the low heart are energetically connected. At midlife, the dictates of our high heart’s desires become increasingly urgent, and our low heart and genitals will no longer willingly participate in sex that is not connected to our high heart and our deepest yearnings.
For many women, libido resurfaces after they have identified their unsatisfied needs and taken steps to get them met. (As discussed in chapter 2, I recommend visiting www.cnvc.org, the website of Marshall Rosenberg, Ph.D., founder of the Center for Nonviolent Communication; here you’ll find both a list of human needs and a list of the emotions that signal when they aren’t being met.) Listing our needs and desires and trusting that we have the power to get these met is the first step toward recharging the batteries of our libido. At midlife, our task is to broaden our concept of sexual energy and appreciate it as life force that may have nothing to do with sex per se. Our culture, through its books, movies, and media images, promotes love and sex as the major—if not exclusive—route to happiness. But this is only part of the truth. When we are fully open to the energy that created the universe in the first place—which is another way of saying when we are in love with our own lives—then we have the ability to tune in to and become part of the vitality of the world around us and in us. It’s everywhere—in the beauty of nature, the pursuit of a cause we believe in, and the exercise of our creative powers. We find that we are capable of becoming passionate about life itself, whether or not we have a sexual partner.
In other words, if we think of sexual energy in the largest possible context—as life force, or as Source energy—then the relationship between the two becomes clear: the health and vitality of our sexuality is inexorably linked to the health and vitality of our lives.