Women are consistently surprised to learn things about their pelvic health that seem quite obvious once we discuss them but have not been a part of previous conversations. For example, we know that caffeine irritates the bladder and results in increased urgency and frequency. We also know that persistent straining for bowel movements can cause concerns with pelvic health later in life such as prolapse. The term prolapse refers to when 1 or more of the organs in the pelvis slip down from their normal position and bulge into the vagina. The second thing I regularly hear is “I had no idea there were people who could help me with this problem”. Pelvic Health Physiotherapists are here for you! We love to talk about all things related to the pelvis. Everyday topics for us include: pelvic heaviness, pressure and prolapse, leaky bladders during the day and at night, and activities disrupted by bladder urgency and frequency, difficulty emptying the bladder, concerns with constipation, incomplete or difficult emptying of stool, reduced control of stool and gas, painful intercourse and other pain including pelvic, abdominal, hip and back. These are all related to pelvic health and good function of the pelvic floor muscles. Perimenopause and menopause can be a time of new symptoms or worsening of previously minor concerns. It takes courage to talk about symptoms in the pelvis because it is so personal. It helps to know there are people who want to help and to know that can often improve your symptoms, confidence and quality of life.

The good news is there are a few straight forward things that can help make a difference for you if you have any of these concerns. As mentioned, caffeine is a strong bladder irritant and will worsen bladder urgency and frequency. Reducing or eliminating caffeine can help. Did you know the bladder can be trained? Often during the period of time leading up to menopause we are awakened more than we would prefer. We get up to use the bathroom when we are awake, whether we need to or not. This becomes a habit and then the bladder starts to wake us up. If you are up to the bathroom more than once at night, consider if the bladder is really full when you wake up or if it is a habit. If the cause is not a full bladder you might just want to breathe, relax and roll over to go back to sleep. From a bowel movement perspective, one of the most important things is to have your stool at a soft, formed consistency. One of the most common reasons for constipated stool is dehydration. Consider your fluid and fibre levels and see if you can start to make small changes. Regular exercise is also important for bowel function because movement creates movement! If we are straining less, then there is less downward pressure into the pelvis and this is helpful to prevent and manage pelvic organ prolapse. As you can see, we will talk about anything!!

Of course this brief discussion would be incomplete without talking about the pelvic floor muscles! Did you know that the pelvic floor muscles go right from the pubic bone at the front of the pelvis, all the way to the tailbone at the back? Did you know there are three layers in the pelvic floor and the deep, inside layer is very important but largely a secret? Did you know it is important to be able to squeeze and tighten the pelvic floor muscles but also relax and lengthen them? Pelvic floor muscles need to be able to turn on and also turn off. Many of the problems which women (and men) experience in the pelvis relate to pelvic floor muscles that are overactive and do not relax effectively. Overactive muscles in the pelvis can cause pelvic and abdominal pain, painful intercourse, bladder and bowel leakage and difficulty with emptying the bladder and bowel. To be truly useful, the pelvic floor muscles need to be able to effectively tighten and relax in a coordinated, integrated manner while we complete our day to day activities with confidence. When we get the muscles working well they help with control of our bladder and bowel, support for our pelvic organs and stability for the spine.

In closing, I would like to highlight the importance of exercise and physical activity on our health status. As we improve our overall fitness and health, we also improve the health of our pelvic floor and reduce our pelvic symptoms. Many common menopausal women’s health concerns can be positively influenced and maybe even prevented with regular exercise. Continue if you are already exercising or start gradually, be persistent, don’t worry about perfect and ask for help if you need it! The World Health Organization Global Recommendations on Physical Activity for Health is a good reference and can be found at https://www.who.int/publications/i/item/9789241599979

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So, it is not surprising that a five year study named the VITamin D and Omega A-3 Trial or Vital has been a topic of discussion at the North American Menopause Society. This is the most recent and largest study to determine if Vitamin D and Omega-3 were effective supplements in the prevention of Cardiovascular Disease and Cancer. The study also looks at the safety with moderate-high dosing of these supplements.

The Vitamin D dosing was 2000 IU and the Omega-3 dose was 1 mg. The Omega-3 used was a prescription version available in Europe and USA. The reason for the prescription is due to the fact that the supplement and herbal industry do not follow the same guidelines and standards that prescription drugs must comply to and consequently there is no guarantee you are actually getting what is on the label. It is recommended that we read the labels and look for the 8 digit Natural Product Number (NPN) or Homeopathic Medicine Number DIM_HM, or if in doubt, talk with your pharmacist when purchasing supplements.

Although the results from the Vital study were not able to give a definitive recommendation for all, and did actually call for more research to answer appropriateness for various medical situations. In other words as they scratch the surface more questions are brought forward.

What the results did find is that certain groups benefit more than others from the supplements. For instance, one finding was that within the Omega-3; those individuals whose diet was low in fish (less than 1.5 servings /week) there was a substantial benefit from the supplement. It found a 19% reduction in major cardiovascular events including a 40% reduction in heart attacks within this group. It also found that for African Americans there was more benefit with Omega-3. At this time there is no recommendation that everyone requires a Vitamin D supplement. It did feel that individuals who have bone health or malabsorption issues, poor Vitamin D dietary intake, or little sun exposure (like those of us who live above the 49th parallel) would benefit from taking the supplement. Osteoporosis Canada advises healthy adults aged 19-50 years old consume 400-1000 IU/daily and those over 50 years old get 800-2000 IU daily.

There were no indicators that Vitamin D reduced the number of heart attacks, stroke, or cardiovascular deaths. The high dose had no increased risk of side effects. Although the findings did not show Vitamin D preventing the development of cancers what was exciting is – a preliminary finding following 2 years of taking Vitamin D regularly there was a 25% reduction in deaths due to cancer. This requires more investigation but is promising to hear.

The Vital study had more results and more questions and is still a process in the works and I have highlighted just a couple – but what can we take so far from this for mid-life women?

Firstly, it demonstrated how the importance of diet and its influence on our health. We should always aim to get these necessary micronutrients from our diets whenever possible. In the past experts have explained how a healthy diet offers 3 main benefits over most supplements:

Nutrition - whole foods have POTENT nutrients.

Fiber - a diet with whole grains, legumes, fruits and vegetables help in the management of constipation and decrease risk of developing diabetes, heart disease and some cancers.

Protection - a number of foods have protective agents like phytochemicals found in plant source and antioxidants which is a substance that can slow down a natural process that leads to cell and tissue damage. These are only two examples of this category.

We also understood that there are life stages and situations when supplements are appropriate. For instance menopausal women would generally benefit from a low dose Calcium supplement because of bone loss associated with the estrogen drop, or for those who have food allergies or intolerances that restricts their diets from a food group- again a supplement would benefit these women. This is an opportunity for each of us to review our meal planning and re-evaluate if we are taking in a healthy diet or if our situation can accommodate the recommendations.

If you have any doubts about your diet and meeting the recommendations - this would be a good discussion with your health care professional who would take into account your medical history, your family history (i.e. family history of heart disease) and your risk factors and make an individualized plan with you for your particular situation.

References: www.vitalstudy.org www.menopause.org –information video

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But what is the science behind these claims, and what should your diet look like if you are concerned about how chronic inflammation is affecting your health?

Inflammation is your body’s natural fight against things that harm it in an attempt to heal itself. When an infection, injury, or toxin is introduced, damage to cells triggers the immune response that eventually brings your body back to its normal, healed state. For instance, if you get a cut, the damaged cells trigger the blood vessels in the area to open up so that immune cells can rush to the site of injury. You’ll experience some redness, heat, swelling, and pain to the area for a period of time as the immune cells go to work, and then the cut will heal. However, in cases of chronic inflammation, this response fails and your body is in a constant state of alertness. Over time, this inflammatory response can start to damage healthy cells, tissues, and organs. This can set the stage for the development or progression of disease. Conditions associated with chronic inflammation include some types of cancer, heart disease, rheumatoid arthritis, fibromyalgia, lupus, type 2 diabetes, obesity, celiac disease, ulcerative colitis, irritable bowel syndrome, asthma, and Alzheimer’s disease.

Nutrition has been found to play a key role in both promoting and combating the inflammatory process. However, always remember that it is the overall pattern of how you eat that is most important, not a single meal or even a day’s or week’s worth of eating now and then. Furthermore, food is a joy, and restriction – especially over- restriction – can take the joy right out of eating, not only for you but also for those who share meals with you. In attempt to build a more anti-inflammatory diet, therefore, we will look more at which foods and strategies to add into your diet, rather than emphasizing the foods and food groups to cut out. First of all, centre your meals around plants. When we think of a plant-based diet, we often simply think of vegetables and fruits. However plant-based eating also includes nuts, seeds, whole grains, vegetable oils, and even coffee, tea, and (gasp!) chocolate and red wine. These foods contain anti-inflammatory nutrients or compounds such as ascorbic acid (vitamin C), vitamin E, polyphenols, and flavonoids, as well as prebiotics. While it may be important to eat some of the above foods in moderation (or not at all, depending on your individual health profile), they can add flavour, variety, and satiation amidst your sea of greens.

Secondly, go for the high-performing fuel. Carbohydrates are your body’s greatest source of energy, and unfortunately, they have gotten a bad reputation over the years. When combined with healthy sources of protein and fat, fibre-rich carbohydrates – such as fruit and whole grains – will moderate your blood sugar curve, provide essential nutrients, and keep you satisfied until your next regular meal or snack. Just keep in mind that a spike in insulin can increase the inflammatory response, so choose carbohydrates that contribute more to your diet than just quick energy, and remember to combine them with other fat-rich or protein-rich foods for the best effect.

Lastly, believe in the power of a healthy fat. The omega-3 fatty acids EPA and DHA help to stop the signaling molecules in your body that promote inflammation, all the while helping to create more of the signaling molecules that prevent inflammation. While fatty fish and fish oil are the most effective omega-3s in combatting inflammation, healthy fats such as chia seeds, walnuts, canola oil, and flaxseed oil may also play a role.

Remember that the best diet plan is one that is individualized to your unique needs – your likes and dislikes, your budget, your habits, your health, and your routine. If you have trouble incorporating the above tips into your life and would like to learn more, seek out a Registered Dietitian to help.

Try the recipe below as an easy lunch to savour at home or pack along to work.

Salmon-Stuffed Avocadoes

½ cup plain Greek yogurt

½ cup diced celery

2 tbsp chopped fresh parsley (or substitute 1 tbsp dried parsley)

2 tsp mayonnaise

1 tsp Dijon mustard

1/8 tsp salt

1/8 tsp pepper

2 cans salmon, drained and flaked (5 ounce)

2 avocadoes

chopped chives for garnish (optional)

Directions:

Combine yogurt, celery, parsley, lime juice, mayonnaise, mustard, salt, and pepper in a medium bowl; mix well. Add salmon and mix well.

Halve avocadoes lengthwise and remove pits. Scoop about 1 Tbsp flesh from each avocado half into a small bowl. Mash the scooped-out avocado flesh with a fork and stir into the salmon mixture.

Fill each avocado half with about ¼ cup of the salmon mixture, mounding it on top of the avocado halves. Garnish with chives, if desired.

 

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However, no guidelines on the use of testosterone in women had ever been published until just recently.

In September 2019, 11 different international professional groups came together to publish the first world-wide agreement paper on how to properly use testosterone in women. They looked at the highest quality studies available and also used the knowledge of the world's top experts on the subject to set out a number of recommendations.

The most important thing they concluded was that testosterone should only be used in women after menopause and should only be used to help increase desire level. Testosterone seems to have a moderate effect on libido, with an increase on average of one satisfying sexual event per month. Testosterone has not proven to have enough effect on general wellbeing, mental processing, dementia, depression, bone strength, muscle strength or total body fat in women.

The guideline-writing panel stressed the importance of identifying all of the factors that are affecting a patient's libido. Women often do best when treatment addresses not just the biological, but also the psychosocial, with interventions like counselling.

Testosterone blood levels decrease in all men and women with aging. As such, the panel recommended that blood levels of testosterone should not be used to diagnose the cause of a woman's low libido. Blood levels of testosterone should mainly be measured to ensure a woman on treatment is not getting too much testosterone. The aim is to reach a blood level of testosterone that is equal to that of a pre-menopausal woman, nothing higher.

No severe negative effects were seen in women with short term use of testosterone. At most, some women may notice mild acne or body/facial hair growth. However, the longest studies on testosterone lasted 24 months, so the effects of testosterone with use beyond that are unknown. Also, women at high risk of heart attack and women with previous breast cancer were not included in most studies, so the safety of testosterone in these women is also unknown and cautious use is advised.

Lastly, Health Canada has not approved any testosterone products for use in women. As such, the panel suggests the careful use of male formulations at female doses. Testosterone creams and gels are strongly preferred, because of the increased chance of negative effects with oral or injection products.

Clearly, more research is required in this area of women's health. However, it is encouraging for patients and doctors to have a published summary of the safest way to use testosterone in women. Hopefully, this paper will serve as a call to action for more study.

 

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Mid-Life Matters Series

Watch for Dr. Renee Morissette on CTV News at Noon with Jeff Rogstad. A series of short segments, Midlife Matters, on women’s health topics will be presented on some Tuesdays during the noon show. Each topic will have a handout which will be on our website www.menopausecentre.org.