What is a Prolapse - By Emily Wong

What is a Pelvic Organ Prolapse (POP)

A prolapse occurs when one or more of the pelvic organs sag or bulges into the vagina. 

The pelvic organs consist of the bladder, bowel and uterus. These are held in place by connective tissue structures known as “ligaments” or fascia”. The pelvic floor muscles provide support from below. When there is damage or stretch to the connective tissue structures, one or more of the pelvic organs can sag into the vagina. 

Women with a prolapse require a thorough examination of the prolapse and the associated symptoms by a doctor or a physiotherapist training in pelvic health.

Types of Prolapse

1. Anterior prolapse (or Cystocele) - the bladder sagging into the front wall of the vagina

2. Posterior prolapse (or Rectocele) - the bowel sagging into the back wall of the vagina

3. Apical prolapse (or Uterine) - the uterus sagging into the top part of the vagina

4. Vaginal vault - the top part of the vagina sagging down (in the case for women who have had they uterus removed)

   Prolapses are graded from 1 (less severe) to 4 (most severe) 

Common Symptoms:

• A bulging or heaviness feeling inside the vagina

• Seeing a bulge coming out of the vagina

• A feeling of a “golf ball in my vagina”

• A feeling of “something coming out of my vagina”

• Obstructive defecation (difficulty doing a poo)

• Incomplete emptying bladder or bowel - problems peeing or pooing

• Feeling heavy or dragging in the lower abdomen

• Discomfort with sex

• Low back pain

What causes a Prolapse?

• Childbirth (Vaginal) - e.g if a woman experienced a long pushing stage or interventions where required like forceps

• Chronic heavy lifting

• Chronic coughing or straining 

• Hormonal changes e.g. menopause

How can I fix my prolapse? 

The management option for prolapse depends greatly on the type and severity of prolapse. As well as the activity level or aggravating factors for the person. An individual approach is best for women with prolapse but here are some management options listed below. Physiotherapists working in pelvic and women’s health are well placed to diagnose and manage prolapses and often will work in conjunction with GPs or Gynaecologists for management.

Treatment options include:

1. Do Nothing - After understanding their own prolapse, its severity and the treatment options available. A woman may decide not to do any treatment and will consider revisiting it later in life if symptoms and/or their prolapse worsens.

1. Non-surgical treatments 

• Lifestyle changes e.g. weight loss, advice around exercise and weight lifting, reducing constipation

• Pelvic floor exercises - individualised prescription is beneficial for improving outcomes

• Vaginal pessaries - objects placed inside the vagina to support the pelvic organs. These are safe to be worn short or long term and there is a growing body of evidence supporting the use of pessaries for prolapse management. At Evolve, the team works closely with gynaecologists to provide pessary fitting.

• Topical oestrogen - prescribed by a GP, this can reduce symptoms of vaginal dryness and irritation

1. Surgery - surgical options can include either using your own tissue, biological tissue or synthetic mesh. Your doctor should explain the type of surgery suitable for your type of prolapse whilst also taking into consideration general health and risk factors.

Women’s and Pelvic Health Physiotherapists are a valuable addition to the multidisciplinary team in managing prolapse. Come and meet our friendly and skilled therapists. 

This information is general in nature and does not constitute medical advice. It is always recommended that you seek input from your medical professional when any symptoms are present.

Written by Emily Wong, Clinical Manager and Senior Physiotherapist Joint Dynamics Evolve

References:

https://www.safetyandquality.gov.au/publications-and-resources/resource-library/treatment-options-pelvic-organ-prolapse-pop 

Menopause and the Pelvic Floor - by Anna Goener

Menopause happens when a woman hasn’t had a period for 12 months and on average occurs at 51 years of age. 

Most women will experience some symptoms of menopause, but the degree and number of symptoms varies woman to woman. Symptoms are caused by hormonal changes and can affect various body systems. The average length of symptoms is 5-10 years. 

Genitourinary Symptoms of Menopause (GSM) is the term used to describe the

changes to the genital and urinary tissues during menopause. Up to 50% of women will experience GSM.

What changes occur in my vaginal and bladder health during and after menopause? 

Aging and reduced levels of oestrogen present during menopause are directly linked to changes in the vaginal and urinary tissues:

• Increased sensitivity of the bladder 

• Reduced number of blood vessels and lower blood flow to the vagina

• Decreased moisture and vaginal self-lubrication

• Decreased elasticity and strength of the pelvic floor muscles

• Increased fragility of tissues

• In-drawing of the labia minora and vaginal entrance

• Changes to the vaginal flora and lower pH levels

How can this affect my pelvic floor symptoms?

Bladder:

• Needing to pass urine more often

• Urgency to pass urine

• Urinary incontinence

• Increased likelihood of urinary infections

Vagina:

• Increased genital dryness 

• Burning/itching sensation of the vulva and vagina

• Decreased arousal or ability to orgasm with sex

• Pain with sex

• Bleeding

• Vaginal discharge

• Sensation of vaginal heaviness or bulging (pelvic organ prolapse (POP))

How can physiotherapy help?

Women’s and Pelvic Health Physiotherapists are skilled in helping women manage pelvic floor symptoms associated with GSM. Your physiotherapist will undertake a detailed history to understand your symptoms, concerns and goals. 

Your Physiotherapist might suggest:

Lifestyle changes

-Changes to your fluid intake 

-Reduction of bladder irritants e.g. fizzy drinks, artificial sweeteners, alcohol

-Optimising toilet positioning and practices

-Advice regarding physical activity and lifting

Pelvic floor muscle training

-Strengthening or relaxation of the pelvic floor muscles

Bladder re-training

-Tools to calm bladder urgency

-Drills to re-train your toileting habits

Electrical stimulation

-Use of electrical impulses to reduce bladder frequency or urgency

Vaginal lubricants and moisturisers

-To improve the moisture content of the vaginal tissues

Vaginal support pessary

-Liaison with a gynaecologist regarding fitting of a pessary to reduce POP symptoms.

The above treatment options are some of the many available tools to help you best manage your vaginal and bladder health during and after menopause. 

Women’s and Pelvic Health Physiotherapists are a valuable addition to the multidisciplinary team in managing GSM symptoms. Come and meet our friendly and skilled therapists. We can’t wait to empower you with knowledge and skills to address your GSM!

This information is general in nature and does not constitute medical advice. It is always recommended that you seek input from your medical professional when any symptoms are present.

References:

Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause. 2014 Oct;21(10):1063-8. doi: 10.1097/GME.0000000000000329. PMID: 25160739.

Australian Menopause Society. (2024). Vulvovaginal symptoms after menopause. https://www.menopause.org.au/hp/information-sheets/vulvovaginal-symptoms-after-menopause

Perimenopause - how to best prepare

Have you experienced a hot flush, a panic attack, insomnia or a change in menstrual flow and been unable to pinpoint the exact cause? These symptoms—and many others—can be early signs of perimenopause. 

While the perimenopause is most likely to start in a woman’s 40s, for some it can begin as early as her 30s, or even earlier in the case of a surgical menopause (a total or radical hysterectomy where the ovaries are removed). And this transitional time can last anywhere from two to 12 years. 

Recognising this important life stage early presents you with greater opportunities to invest in your health, build a strong foundation and manage any troublesome symptoms. Here are five tips to help you navigate perimenopause and make it a positive and empowering journey.  

1. Knowledge is power

Menopause marks the one year anniversary of your last menstrual period, whereas perimenopause is the time period prior to this when you’ll have cycles, but start to experience menopausal symptoms. It is characterised by incremental changes in female hormones, namely oestrogen and progesterone. For some women these changes can be very subtle, but for others this period can be significant and have a huge impact on quality of life. Due to the hormonal shift a wide range of symptoms can appear and they can evolve and change in subsequent years. 

Typically, in the early stages of perimenopause, oestrogen levels are relatively high compared to progesterone and this can cause heavier periods and also shorter menstrual cycles. Symptoms such as breast tenderness, headaches, night sweats, insomnia, anxiety and hot flashes can dominate. Towards the later stages of perimenopause, as women approach menopause, oestrogen declines and periods will become less frequent and unpredictable. Different symptoms may start to occur such as bladder urgency and frequency, painful sex, and joint and muscle pain. 

Management of these symptoms can be as simple as addressing lifestyle factors such as sleep, nutrition and stress management. Further treatment may include topical oestrogen or menopausal hormone therapy, which is best known as hormone replacement therapy (HRT). While, historically, HRT has courted controversy, doing your own research, talking to your GP and finding what works for you is the most important message. Everyone's experience of this transition will be unique, however, understanding the process will enable you to be proactive and reach out for help when necessary.

2. Track your period and symptoms

The best way to recognise the signs of perimenopause is to track your period and work out what is “normal” for you so you can then identify changes in your period or accompanying symptoms, their severity and impact on your daily life. Your period can change over the years, and as you get older typically your cycle gets shorter and increasingly irregular. Cycle tracking should include information such as length, flow and symptoms including pain, cramping, mood, sleep and gastrointestinal changes. There are plenty of apps that can assist with tracking, including Clue, Eve, Flo and Spot On. If you have further concerns about your menstrual cycle, seeking medical support is recommended.

3. Keep moving

Exercise during the perimenopausal life stage is non-negotiable and its benefits are well researched. It has a positive influence on so many different body systems, including the cardiovascular, mental, digestive and musculoskeletal.

Did you know that one in three women over the age of 50 will experience a fracture due to osteoporosis? Exercise is crucial to maintaining good bone health in your perimenopausal years and builds a solid foundation for the future. From your 40s, you begin to lose more bone than you make and this process continues at pace until the menopause. The good news is, it’s never too late to take action, as your bones are constantly changing and will respond to stress and load. This is why high-impact activities such as jogging, tennis, dancing or simply stomping up the stairs builds healthy bones. Strength training, body weight exercises such as planks, squats, lunges and resistance band exercise should also be a priority as they help to maintain muscle mass and body strength, both of which decline with a reduction in oestrogen. Movement is also essential to supporting regular bowel function and in turn a healthy pelvic floor system. 

4. Address any pelvic health issues

Don’t let pelvic floor symptoms become a roadblock to exercise or life quality. A significant number of women—upwards of 54 percent—suffer symptoms such as painful sex, urinary or anal incontinence, and urinary frequency—and accept them as a normal part of ageing without seeking medical help. The decline in oestrogen in perimenopause can lead to changes in the genito-urinary system, but there are plenty of things you can do. A good starting point is a women’s health physiotherapist for specific assessment and treatment of any pelvic floor issues. Research supports pelvic floor muscle strength re-training programmes, which can help to treat stress incontinence. Individualised help can also address many less-talked-about issues such as painful sex, vaginal dryness and flatus. Some quick fixes may be as easy as using a vaginal lubricant, pelvis and/or hip stretches or changing sexual positions. 

5. Ride the wave

Feeling moody, anxious or irritable are some of the more commonly reported emotional experiences associated with perimenopause. Accepting that these feelings may occasionally surface and be part of your perimenopause journey is the first step. It may also be worth considering whether some of these things need a closer look. Are you always getting irritated by the same thing? Perhaps it’s the situation you’re in that needs changing. Have you always felt a bit anxious, but now it’s worse? Try learning some anxiety management strategies. Keep track of your moodiness and other emotions in the same way you would your cycle. This can help you to recognise, accept and ride the wave. If you need time for yourself, take it. Stop putting everyone else first. 

It’s worth remembering that perimenopause and menopause are natural processes that our bodies are designed to go through. Consider the other things our bodies are designed to do: to move—all the time. Where are our stress levels designed to be? Low—only triggered by an actual threat to our physical safety. What diet is our body designed to need? Fresh produce, whole foods, nothing artificial. How are we designed to breathe? Slowly, deeply, fully. We’re meant to connect with nature—trees and soil release microorganisms that are beneficial to human health. The more you can get back into balance with the things that your body is designed to do, the more you can ride the wave of perimenopause with less anxiety and resistance.

Kathryn Gale is a registered psychologist and mindfulness meditation coach at Joint Dynamics Evolve.

Kym Toller is a women’s health physiotherapist at Joint Dynamics Evolve.

Menopause, Osteoporosis and Strength Training

With a compelling amount of women being associated with the status of menopause and osteoporosis, it is essential to do exercise, especially strength training.

Perimenopause holds a number of physiological changes which have significant implications for both physical and mental health. One of the most prevalent being osteoporosis from oestrogen deficiency during this period, causing a risk of bone fractures and bone weakening disorders. Despite that, most of the physiological changes can be helped positively through exercise, particularly strength training.

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Middle-aged women tend to have smaller muscle mass than middle-aged males. Despite the few biological reasons for this, a lot of the decline in strength and muscle mass that occurs through perimenopause belongs to the lack of exercise stimulus along with biological reasoning. Women as a whole do not engage in enough exercise or strength training as men do.

Strength training should be a main priority of exercise for middle aged women and above, to help build bone around vulnerable areas such as the hips, spine, and arms to prevent osteoporosis. While providing other benefits such as managing weight, improving balance, relieving or decreasing pain, maintaining muscle mass, and improving cardiovascular health. Exercise can help cardiovascular diseases by lowering blood pressure and cholesterol. While strength training also helps reduce body fat, specifically visceral fat during menopause and increase muscle mass

For both muscle and bone, it becomes much harder to add extra once you are post-menopausal, compared to pre-menopause. Starting before the onset of menopause gives women the best chance at building the strength they will need for a resilient older age. That being said, it’s never too late to start!

Written by Georgia Cutt, Exercise Physiologist

How to support a friend when the journey to conceive is long…

As Evolve’s Psychologist, I speak with people who are trying to conceive, oscillating between hope and hopelessness, at times feeling totally alone and desperate, often stressed and anxious. Good days are mixed with bad days and it’s the full emotional roller coaster experience.

For friends wanting to offer love and support, there’s no clear answer as to what’s best. It depends on the person, and where they are at that moment in time. It’s so hard to know what the ‘RIGHT’ thing to say is. 

There are some things though that, generally, are more helpful, and some things that can be triggering for the person although so well-meaning. 

Because each day is different, here are 4 suggestions for showing love and support:

• How are you today? (On the emotional roller coaster, each day can be different)

• Do you want to talk about it? I totally understand if you don't want to talk.

• I always want to hear how you're going, but I don't want to bring it up every time I see you in case you don't want to talk about it, but do know I'm here whenever you want to talk.

• We want to be able to instil hope and share ideas, but just listening, rather being solution-oriented, can provide the best support. Wait until they ask you for ideas.

When you’re listening, you could say:

• "It sounds like you're doing all the right things"

• "It's such a tough time for you - I so admire your strength in moving through this"

Despite coming from the best of intentions, sometimes these comments can be hard to hear:

• Have you considered all the options?

• At least you can enjoy trying

• Lucky you already have one

• Don't stress - it'll happen when you stop worrying about it

I think the hardest part of listening to a friend going through a difficult time (regardless of the situation) is feeling so helpless. We think ‘I just wish there was something I could do!!! I just want to fix this for you!!! I hate to see you in so much pain!!! 

So it seems counterintuitive that the best thing you can do is just listen, be present, and show that you’ve heard what they’re saying. That’s it. If you’re asked for ideas or solutions, absolutely go ahead, but if not, listening is the best way to express your love. 

Sending lots of love to those on a long journey to conception, and their brilliant support networks. For more info or tips I’m at kathryn.gale@jointdynamics.com.hk