Bladder Leaks, UTIs & Pelvic Floor Health with the Vagina Whisperer

In this episode of unPAUSED, Dr. Mary Claire Haver sits down with Dr. Sara Reardon, board-certified pelvic floor physical therapist, founder of The Vagina Whisperer, and author of Floored, to talk about the muscles 68% of postmenopausal women say no one ever taught them they had. Nearly 1 in 3 women lives with a pelvic floor disorder — urinary leakage, prolapse, pain with sex — and the US spends over $20 billion a year managing it rather than fixing it, while women are offered a device, surgery, or “just live with it.” Dr. Reardon explains why leaking isn’t just part of being a woman, why diapers aren’t your destiny, and why these symptoms are treatable at every age. Dr. Reardon walks through what happens at a pelvic floor PT appointment (you can self-refer in every US state, covered by insurance), why over 50% of women do Kegels incorrectly — and why Kegels alone were never the answer — the difference between a weak and a too-tight pelvic floor, and stress vs. urge incontinence. They dig into night-time bathroom trips and the fall-and-fracture risk nobody connects to them, why vaginal estrogen should be prescribed proactively — including the study showing it cut recurrent UTIs from 5.9 infections per patient-year to 0.5 — the truth about prolapse (half of women over 50 have some degree of it), what to ask before consenting to any prolapse repair, and the vaginal mesh scandal. Framed throughout by Mary Claire’s own mother’s story: three failed incontinence surgeries, decades of leaking, and the hip fracture after which she never walked again. Guest links: Dr. Sara Reardon / The Vagina Whisperer (Website) https://www.thevagwhisperer.com/ Dr. Sara Reardon (Instagram) https://www.instagram.com/the.vagina.whisperer/ Books: “Floored: A Woman’s Guide to Pelvic Floor Health at Every Age and Stage,” by Dr. Sara Reardon https://www.thevagwhisperer.com/floored “The New Perimenopause,” by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book “The New Menopause,” by Dr. Mary Claire Haver https://www.amazon.com/dp/B0CKBZ4K1Z Never miss an episode—sign up for The ‘Pause Life Newsletter: https://thepauselife.com/pages/newsletter Medical Disclaimer: The information, including opinions and recommendations, on this platform is meant for informational and educational purposes only. Mary Claire Media, LLC, the unPAUSED podcast, and The ‘Pause Life are not medical organizations. Medical advice or medical diagnosis cannot be provided to you through the platform, any associated website, or customer portals. Using this platform does not establish a patient-physician relationship.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Speaker 00

  We've been told the narrative that diapers are our destiny, or that pelvic floor issues are just part of being a woman when they're not.

• 0:06Dr. Mary Claire Haver?

  68% of postmenopausal women who were surveyed didn't even know what a pelvic floor was.

• 0:11Speaker 00

  It feels very scary to hear, "Your bladder is falling out of your vagina."

• 0:15Dr. Mary Claire Haver?

  She gets a 60-second exam, is told, "Your bladder is falling out, just don't lift anything heavy."

• 0:20Speaker 00

  And dismissing it, which is complete gaslighting.

• 0:23Dr. Mary Claire Haver?

  Right now, she gets offered three things: buy a device, get surgery, or live with it.

• 0:28Speaker 00

  Or live with it, and there's so much we could do. In every state in the United States, you can self-refer to physical therapy for your pelvic floor. And it's covered under insurance like every other type of physical therapy. We're asking women to live half of their lives with these symptoms that are very treatable.

• 0:52Dr. Mary Claire Haver?

  The views and opinions expressed on UnPaused are those of the talent and guests alone, and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional medical advice, diagnosis, or treatment. Nearly 1 in 3 women lives with a pelvic floor disorder. From urinary leakage and prolapse to sex that hurts. And in the United States, we spend over $20 billion a year just managing it, not fixing it, treating it. Liners, medications, surgeries, then repeat surgeries, because roughly 30% of women who have surgery to fix a pelvic floor problem end up needing a second one for the same condition.

• 1:36Dr. Mary Claire Haver?

  You've heard the script your whole life. Leaking is just part of being a lady. Your bladder is falling out of your vagina, just don't lift anything heavy. Some pain with sex is normal. Try to relax. These are not medical answers. They are a system telling you to go home and manage it quietly. 68% of postmenopausal women said no one ever taught them what their pelvic floor even is. We are told more about erectile dysfunction than about pelvic organ prolapse, a condition that affects half of all women over 50. That is a decision about what medicine chose to study and to fund. My guest today, Dr. Sarah Riordan, has spent two decades in the room where women finally get the truth.

• 2:20Dr. Mary Claire Haver?

  She's a board-certified pelvic floor physical therapist, the founder of The Vagina Whisperer, where she educates people about everything, from pelvic health to menopause. And she's the author of "Flord: A Woman's Guide to Pelvic Health at Every Age and Stage." I'm Dr. Mary Claire Haver, a board-certified obstetrician and gynecologist and certified menopause practitioner, and adjunct professor at the University of Texas Medical Branch. Welcome to UnPaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life.

• 2:59Dr. Mary Claire Haver?

  Dr. Sarah Riordan, welcome to UnPaused.

• 3:02Speaker 00

  Thanks for having me.

• 3:03Dr. Mary Claire Haver?

  So tell me, I like to ask this question of everyone, how does menopause really show up in your practice?

• 3:08Speaker 00

  As a pelvic floor physical therapist, we see women of all ages and stages. Particularly with perimenopause and postmenopausal patients, we see a lot of hormones starting to change. So some of the symptoms they may present with are urinary leakage, increased urgency and frequency, so peeing more frequently during the daytime and nighttime, pain with sex. It could be sex that's painful, uncomfortable, even causing tearing or irritation to the tissues. And then pelvic organ prolapse, which can feel like pressure or heaviness in the vagina. So they're all pelvic-related symptoms. We often think that this is something that's a normal part of aging. But menopause and postmenopause is over 40 years of our life, depending on how long we live. So we're asking women to live half of their lives with these symptoms that are very treatable.

• 3:53Dr. Mary Claire Haver?

  So let's break it down for our listeners, because I said in the intro that 68% of postmenopausal women who were surveyed didn't even know what a pelvic floor was. So we brought a model today for those of us on video. What is the pelvic floor?

• 4:09Speaker 00

  Your pelvic floor is literally the floor of your pelvis. So you have this ring of bones that sits at the base of your spine. And at the bottom of this is a basket of muscles. And they attach from the pubic bone to the front, to the tailbone in the back, and side to side. So these muscles support your pelvic organs. They have the sphincters that hold in urine and stool throughout the day. They have the vaginal opening for vaginal intercourse, vaginal birth and menstruation. And they also work synergistically with your postural muscles to support your spine. So these muscles are working for us all throughout the day. But as you mentioned, it's not often until someone has a pelvic floor problem do they even know the pelvic floor muscles exist.

• 4:48Dr. Mary Claire Haver?

  So I used to explain it to patients as there are no bones holding your girl parts and your organs in. You know, it is a hole. And that hole is, there's a hammock there. And so when I was trying to explain prolapse, it's a hernia, you know?

• 5:03Speaker 00

  That's exactly right.

• 5:04Dr. Mary Claire Haver?

  Most people understand the concept of a hernia. Like you have a hernia in your vagina, in your pelvic floor, somewhere that's letting these organs kind of slide out, where these muscles and tendons used to hold everything up and together.

• 5:15Speaker 00

  That's right.

• 5:16Dr. Mary Claire Haver?

  So NHANES is one of the bigger studies, right? And it put any pelvic floor disorder in the United States at 23.7% of women. But that increases to over 50% by the time we're 80.

• 5:32Speaker 00

  Yeah. So that's 1 in 4 women at some point in their lifetime experience a pelvic floor issue. And I actually think that's an underestimation. The other thing is that we're seeing studies that show that at the age of 65, 50% of women leak urine. So it's actually more prevalent than even that 50% at 80 years old. What this tells us is that we've been told the narrative that diapers are our destiny, or that pelvic floor issues are just part of being a woman when they're not. There's a lot that you can do to educate ourselves early, to be proactive and preventative, and then to treat these issues sooner if they're going to occur, because we know how common they are among women.

• 6:11Dr. Mary Claire Haver?

  I can remember, you know, my mother had three separate incontinence surgeries. And so mom leaked and leaked and leaked and leaked and leaked. And I can remember her bathroom always smelled like urine. Like, and she loved her some pantyhose. And that was her underwear. But she liked to have her leg, anyway. Back in the, she had the legs, do you remember? But like, she would wash them, and like, they would always be hanging. And she always leaked. Like, we took her and my dad to Disney World when the kids were little. And I can remember hugging her. And she didn't have a bag big enough to fit her pads.

• 6:45Speaker 00

  Oh, goodness.

• 6:45Dr. Mary Claire Haver?

  Because we were going on rides. And so I hugged her, and I could feel she'd put them as shoulder pads in her t-shirt. And like, her life was ruled by this incontinence. And no surgery was able to kind of get her back to her normal functioning. You know, they over tighten her on one of them, and that was its own disaster. So it really did affect my family. And then when I went into practice, I thought that was a normal part of aging. Like, we just had our first year of gynecologist on staff when I was a resident. So I learned the POPQ, like how we measure prolapse and stuff. And I just kept thinking about my mother and how she never was offered this stuff, or any therapy, or anything, and how miserable she was for 30 years of her life.

• 7:30Speaker 00

  Yeah. You know, it's, these are the stories that I hear that make me realize how much work we have to do with the medical system. And this is why we're having this conversation, is that we have to start talking about the problems. I always say, "We've normalized the problems, but not normalized the conversations." So what your mom experienced...

• 7:49Dr. Mary Claire Haver?

  I have to steal that. I'm sorry. Say that again?

• 7:51Speaker 00

  "We have normalized the problems, but we need to normalize the conversations." And the reason for that is that if we don't address these issues sooner, they will end up exactly like your mom did. Where it's actually impressive that she was able to travel, even to go to Disney World, because there are women in their 40s and 50s who don't want to do that, because the bathroom's not accessible, they're worried about the odor or scent. There can be skin breakdown from heavy pads and leakage. So the sequelae of these symptoms can be very significant, and it impacts your quality of life, where you can't take the trip with your grandchildren, or you can't travel with your partner, or go on a road trip. So it's also indicative of the mental load that your mom had to carry. You know, I tell this story that I'm The Vagina Whisperer, right?

• 8:36Speaker 00

  Sarah Riordan, I've been a pelvic floor therapist for 20 years. I've never had a pelvic floor issue. I had really wonderful births and postpartum recoveries. And at the age of 41, I decided I'm going to start playing tennis. And so I was out on the court, doing my thing, and I took a quick step, and I felt myself leak. And I was like, "Ah." Sarah, you just peed your pants. And I'm going, I'm the vagina whisperer. This is off brand for me. Like, I can't have wet yoga pants. And then for the entire rest of the match, it was, okay, should I make that movement? Can anybody see it? What happens if it happens again? What do I do? And it completely consumed my mental space where that's all that I could focus on. And it gave me real empathy for what women are experiencing when they're having a pelvic floor issue, that it consumes. It's not just a physical issue.

• 9:21Speaker 00

  It really is emotional and mental as well.

• 9:23Dr. Mary Claire Haver?

  You're planning your whole life around it.

• 9:25Speaker 00

  Correct.

• 9:25Dr. Mary Claire Haver?

  So, right now, when a woman hits your office, finally, like, figures out, okay, there's something I can do about this, and she gets the referral. I'm imagining you don't get a lot of self referrals.

• 9:37Speaker 00

  We actually do get a lot of self referrals.

• 9:38Dr. Mary Claire Haver?

  Because I don't think a lot of women even know that. What I'm hoping, if the main takeaway of this podcast, is that they understand that people like you are in the world, and a patient can get herself there.

• 9:48Speaker 00

  Absolutely. In every state, in the United States, you can self refer to physical therapy for your pelvic floor. And it's covered under insurance, like every other type of physical therapy. A lot of us practice what we call out of network. But there are pelvic floor therapists all over the United States. But physicians can also refer you, or any medical provider. So, you can ask your medical provider for a referral. I think most often, word of mouth is the best way to find out. And there are a lot of things that are difficult or challenging about social media. But I think the rise of pelvic floor therapy is one of the positive ones, because now more women know this option is available, and they can start seeking it out for themselves. So, I have a board certification in pelvic and women's health, physical therapy. And so, that requires additional training and test taking.

• 10:32Speaker 00

  And that's important, because not every physical therapist knows how to do this. And there is additional training to call yourself a pelvic floor therapist that's needed in order to practice this.

• 10:42Dr. Mary Claire Haver?

  Okay. So, she gets into your office, and what does she think is going to happen when she gets in?

• 10:49Speaker 00

  One of the questions I get is, what should I wear? I'm like, you can wear nothing, because we're going to be getting undressed. So, typically, the initial evaluation is one-on-one with a therapist in a private treatment room. So, it's not like you're going to be in this big PT gym, doing exercises with a bunch of other people with knee replacements. It's a private room, and you sit down one-on-one with a physical therapist, and you just talk. We ask a lot of questions. I really think that women know their bodies best. And if we just listen to their stories and their symptoms, I can start putting the puzzle pieces together in advance, and then the physical examination just confirms what I'm, my hypothesis is. And so, we'll talk, I'll ask all about their pelvic floor symptoms. So, you may be here for painful sex, but I want to hear about your bowel health, your

• 11:34Speaker 00

  bowel health, your bladder health, your childbirth history, exercise, medication.

• 11:37Dr. Mary Claire Haver?

  Why is that important?

• 11:38Speaker 00

  Because it's all connected. These muscles, these muscles are integrated into all of these functions. So, you may be here for urinary leakage, but your constipation could be contributing to your urinary leakage. So, I want to get a full picture of what's going on. And then, we do an external assessment, looking at your abdominal wall, checking your hip strength and your posture. And then, I step out and let you get changed, and you undress from the waist down. You're covered up with a sheet or a gown. And then, we do the internal pelvic floor muscle assessment, inserting a glove lubricated finger into the vaginal opening. And that's how we test the pelvic floor muscles. Not everyone has to have an internal exam, but it is the direct way to assess the muscles.

• 12:20Dr. Mary Claire Haver?

  So, on this, on this model, which muscles are you testing and pressing on?

• 12:24Speaker 00

  So, all of these, this red material, is considered the pelvic floor. And then, you've got two layers of muscles. You've got the outer layer here, and then, you've got this deeper bowl layer. That's the supportive structure. So, when, I'm just first looking at the muscles. I'm looking at the tissues, the labia, the clitoris, to see if there's any irritation or sensitivity. We can often tell if someone has lower estrogen levels, just by visually inspecting the tissues.

• 12:48Dr. Mary Claire Haver?

  Right.

• 12:48Speaker 00

  And then, I'll ask them to contract.

• 12:50Dr. Mary Claire Haver?

  That's when we lose our labia.

• 12:51Speaker 00

  That's when we lose our labia. Dr. Rachel Rubin has informed us all. And then, I ask them to contract. So, do what you would consider a Kegel contraction, is how I cue them. And we know that over 50% of women are not doing Kegels properly, when verbally instructed. So, it just gives me an indication of, can they connect mind and body? And then, I ask them to push or bear down, like they're having a bomb movement or giving birth vaginally. And then, I insert a finger into the vaginal opening, and I test the muscles on the left side and the right side, just pressing with my finger, and then, again, assess strength.

• 13:24Dr. Mary Claire Haver?

  Okay.

• 13:24Speaker 00

  So, it's like testing any other muscle in your body.

• 13:27Dr. Mary Claire Haver?

  Okay. Right now, she gets offered three things. Buy a device, get surgery, or live with it. What are we missing here?

• 13:37Speaker 00

  A lot. I think the first step is more investigation. What has caused these symptoms to occur? Because often, these are progressive. It's not the first time someone leaks, or has pain with sex, they come into therapy. It's when the symptoms have gotten bad enough, that now, they're affecting their quality of life. So, I want to hear more about what caused them, what's contributing to them. The second is education. As you mentioned, a lot of women don't even know that their pelvic floor muscles exist. And so, we're going to guide them to treat with these other devices that maybe have minimal efficacy, no long-term effects. Once they stop using them, the effectiveness goes away. And the patient still doesn't understand how to connect with this part of their body and use it.

• 14:21Speaker 00

  And then, long-term maintenance planning. You know, I always say, going to see a pelvic floor therapist is like going to see a dentist. Once you get a cavity fixed, you don't stop flossing or brushing. It's the same thing with your pelvic floor. Once you get a symptom resolved, you have to have a maintenance program for a long-term resolution, and to prevent things from getting worse down the line. So, we really need to look comprehensively, before just saying, use this device, sit on this Kegel vibrating chair, insert a wand into the vagina. These are all very short-term fixes.

• 14:53Dr. Mary Claire Haver?

  We will go through all of those later. In your book, and I picked this story, because I really, I've heard this story in my clinic, dozens of times. Beth, 45, always a nurse.

• 15:04Speaker 00

  Yeah.

• 15:04Dr. Mary Claire Haver?

  Right? Always on her feet, you know. A lot of people who, cosmetologists who do hair, you know, all these jobs where we stand all day. She feels a lump at the opening of her vagina. She gets a 60-second exam, is told, your bladder is falling out, just don't lift anything heavy. What should that appointment sounded like?

• 15:27Speaker 00

  I mean, a lot of what we just discussed, like, investigate more. You know, first of all, Beth is a nurse. She has to lift for her job. So, what are you telling her? That you can't lift your kids? That you can't do your job?

• 15:37Dr. Mary Claire Haver?

  Lift your patient?

• 15:38Speaker 00

  Right. So, this is something that it's not as simple as, hey, just avoid the thing that made this happen. So, I think we need more investigation. We need, what makes it better? What makes it worse? What do you do that makes it worse? And then, I think we also need to give her options. What can you do for this? Is it pelvic floor training? Is it a pessary? Is it surgery? Kind of really present to her her options, instead of just ignoring it and dismissing it, which is complete gaslighting. And the last thing is, we need education. Prolapse is scary for women.

• 16:08Dr. Mary Claire Haver?

  Yeah.

• 16:09Speaker 00

  If you look at this online, or even if you see it on your own body, it feels very scary to hear, your bladder is falling out of your vagina. But the reality is, it's actually just the vaginal walls that are getting pushed in from the organ. So, nothing's really falling out. But I think we really need to help women better understand their bodies, because we're not educated on this.

• 16:28Dr. Mary Claire Haver?

  Yeah. Here's a woman I want you to talk to. She has been doing her Kegels faithfully.

• 16:34Speaker 00

  Always.

• 16:35Dr. Mary Claire Haver?

  For 10 years, because it's what anybody told her to do. She still leaks when she sneezes. Sex burns. She keeps getting UTIs, and she thinks she's failing at her Kegels. What's actually going on with her, do you think?

• 16:49Speaker 00

  You know, when I hear this, my first thought is, these are all symptoms of genitourinary syndrome of menopause, and is she using topical vaginal estrogen? Because anyone that I see that has these symptoms, I'm aware that pelvic floor training is a piece of the puzzle. But if we don't get those tissues in the right space. Healthy, thick, lubricated, these symptoms will persist. And so, it's a combination of talking to her medical provider about topical vaginal estrogen. I also often recommend vulva moisturizers and balms. I say, we have a whole skincare routine for our face. We need to have a vulva care routine as well. And then, I would want to know more about her Kegel routine. Is she someone who just does them while she sits at red lights? Right? Is that doing her Kegels?

• 17:33Speaker 00

  Where we know this exercise has to be progressive, it has to be built into function, you have to strengthen these muscles, you need to do quick contractions, longer hold contractions, do them in standing, do them with movement. So, it's not just the do your Kegels that are going to help you.

• 17:49Dr. Mary Claire Haver?

  So, there's a man, I didn't know this, so this fascinated me, Arnold Kegel?

• 17:53Speaker 00

  Yes.

• 17:54Dr. Mary Claire Haver?

  Of course, it was a man.

• 17:55Speaker 00

  Of course.

• 17:56Dr. Mary Claire Haver?

  Well, they were all the doctors back then. So, built a pressure machine in the 1940s. And we turned that one measurement into the answer for everything in the pelvic floor. Why have we stuck to this for 80 years?

• 18:08Speaker 00

  You know, Dr. Kegel gets a bad rap, because it's all we've been told about the pelvic floor. Any issue you have, whether it's leakage, discomfort with intercourse, you know, you want more sexual satisfaction, do your Kegels. It's the equivalent of, if someone has back pain, we just say, do a bunch of crunches, and it should be fine. What I will say, Dr. Kegel brought a lot of awareness to the pelvic floor muscles, that strengthening and rehabilitation is necessary, particularly in his postpartum patients, is where he did the research.

• 18:37Dr. Mary Claire Haver?

  There are symptoms of a pelvic floor being too weak?

• 18:40Speaker 00

  Yeah.

• 18:40Dr. Mary Claire Haver?

  And there's a symptoms of a pelvic floor being too tight. What does that look like?

• 18:44Speaker 00

  So, this is a difference. This is a great thing to bring up, because your pelvic floor muscles are like any other muscle in your body. They can contract, but they also need to relax, just like your bicep. And so, if you have pelvic floor tension, and you're doing a bunch of Kegels, that could actually be making your issue worse. Some symptoms, common symptoms, that are associated with pelvic floor tension are difficulty initiating your bladder stream, feeling like you are not emptying completely, feeling like some things left in your bladder after you're done, straining with bomb movements, hemorrhoids, fissures, incomplete bowel emptying, pencil fin stools. And then, pain is a big one. So, painful intercourse, painful orgasms, tailbone pain, deep hip pain.

• 19:29Speaker 00

  All of those things are tension-related. When we think of weakness, it's more of a support or weakness issue, like urinary leakage, fecal incontinence, staining in the underwear, pelvic organ prolapse. But what's most important is really getting a proper diagnosis, as to which one you can fall in. Because you can actually have leakage and still have tension, and you have to treat the tension first.

• 19:54Dr. Mary Claire Haver?

  Buy smart, drive for less, and trade for more. That's Toyota affordability, and it all starts with a great deal from your local Toyota dealer. Make a smart buy on an all-wheel-drive Camry, Corolla Cross, or get a Corolla sedan packed with the latest features, advanced tech, and head-turning style. Take a test drive in two of Toyota's most popular SUVs, the spacious, family-friendly Grand Highlander and adventure-ready RAV4. And with so many hybrid and plug-in hybrid models available across the lineup, plus efficient all-electrics like the BZ, BZ Woodland, and all-wheel-drive CHR, you can drive your way and skip the pump.

• 20:35Dr. Mary Claire Haver?

  And long after you leave the lot, your Toyota keeps delivering with legendary resale value built on a reputation for quality and reliability. So when it's time for your next Toyota, you could trade in for more. From a great deal today to a great value tomorrow. A Toyota is right for you. Shop toyota.com for deals and details, or stop by your local Toyota dealer today. Toyota, let's go places.

• 21:06Dr. Mary Claire Haver?

  So there's a Cochrane review, and this is where we get pushed back, right? Like, Kegels should fix everything. That showed pelvic floor muscle training works for stress incontinence. So, and we can talk about the types of incontinence. 56% cured versus 6% with no treatment. But what I don't think people realize, this wasn't a doctor handing you a pamphlet saying, "Go home and do your Kegels." This was like intensive physical therapy.

• 21:31Speaker 00

  Right. It was 12 weeks of physical therapy, individualized with a pelvic floor therapist. So what we see here is the brochure to do your Kegels is not effective. People need consistency, they need accountability, they need nuance. You know, how I'm gonna do an exercise is gonna be different from you. And we need progressive loading. We talk a lot about progressive loading and strength training.

• 21:55Dr. Mary Claire Haver?

  I've never talked about that until the last two years.

• 21:57Speaker 00

  But we talk about it for every other muscle in our body, but also is necessary for the pelvic floor. You have to increase intensity and load over time. So again, sitting in your chair or in your car doing Kegels is not gonna be what helps you prevent leakage walking to the bathroom. It is gonna be training these muscles for the function that you need them to do. So someone who's a runner, or a jumper, or a heavy lifter, is gonna need a different type of training than someone who just needs to be able to walk and hold her bladder with the urge to go. But it's important that we think about function and not just one simple exercise.

• 22:30Dr. Mary Claire Haver?

  We had an audience question.

• 22:31Speaker 00

  Great.

• 22:32Dr. Mary Claire Haver?

  So what is biofeedback therapy? And how does it help a woman actually find and control these muscles when she can't feel whatever the hell's going wrong?

• 22:41Speaker 00

  Right. Well, and one of the reasons we can't feel what's going on is we've never connected to this part of our body. We are never trained on it. And then, once we are even aware of it, there's often something already wrong. Biofeedback is a term used to describe a device, oftentimes a device, that gives us feedback about how our body's performing, but we can see it externally. I compare it to an EKG for the heart. You hook the leads up to the chest, and then you can see your heart muscle contractions on a screen. For the pelvic floor, it's usually an internal or external device in the vagina or anus, or externally around the perineum. And when you do a pelvic floor or Kegel contraction, you can see the contraction and the relaxation on a screen. Sometimes it's on your iPhone, sometimes it's on a separate device.

• 23:23Speaker 00

  So it's giving you a visual feedback as to what your body is doing. And then you can say, "Okay, I'm not relaxing well enough. Let me try kind of better relaxation, maybe taking some deep breaths or changing positions." Or, "I'm not holding long enough. Maybe if I'm in standing, I need to go to sitting and take gravity out of it." So it gives us a way to kind of see what our body is doing. I like it for an initial attempt to train folks on how to use their pelvic floor. But ultimately, we need to be using these muscles and function and exercise throughout the day. So we want to move off of those devices eventually so that people can just have this routine, this training as part of their lifestyle.

• 24:03Dr. Mary Claire Haver?

  Okay. Let's, let's talk about the urinary system. Let's focus on that for a little bit. So according to Kaiser, so huge medical system, and you know, based in California, they looked at their data, and 34% of women over 40 are up one to two times at night to pee. That's just the women who said it. "We're not screening for this." I'm not, you know, it's not a standard screening in an OB-GYN office, "How many times you get up at night to pee?" She has to like complain about it.

• 24:32Speaker 00

  Yeah.

• 24:35Dr. Mary Claire Haver?

  Why, why is this so high? We should be sleeping all night.

• 24:39Speaker 00

  Correct. So the normal range to pee at night is actually zero to two times. So it's somewhere within that normal range.

• 24:45Dr. Mary Claire Haver?

  But normal means common, not that it's not pathologic.

• 24:47Speaker 00

  Correct. And why this is important is because we know what lack of sleep does to a woman when they're already perimenopausal and postmenopausal. We already have brain fog, we already have anxiety, we've got fatigue.

• 25:01Dr. Mary Claire Haver?

  Weight gain.

• 25:01Speaker 00

  Weight gain.

• 25:02Dr. Mary Claire Haver?

  Visceral fat deposition and increasing risk of dementia and heart disease.

• 25:06Speaker 00

  Exactly.

• 25:06Dr. Mary Claire Haver?

  And this is a big deal.

• 25:07Speaker 00

  It's a huge deal, and this is why I love this conversation, because why is she waking at night? Because of her urinary tract and pelvic floor health. And so we have to get to the root cause of what's causing that. Some of it could be her dietary intake and fluid intake. Some of it could be medication-related.

• 25:23Dr. Mary Claire Haver?

  Women don't turn 45 and become idiots, you know? They know, "I'm gonna restrict my, if I'm getting up at night, maybe I'm drinking too much." So I don't have a single patient who comes in who hasn't restricted her fluid intake, you know, before she complains about this.

• 25:35Speaker 00

  So what's interesting is that restricting your fluid intake can also concentrate your urine. I know.

• 25:39Dr. Mary Claire Haver?

  And make it more irritable.

• 25:41Speaker 00

  My first question for all of them is, are you using topical vaginal estrogen? I really am a believer that this should be prescribed perimenopausally.

• 25:49Dr. Mary Claire Haver?

  Me too.

• 25:49Speaker 00

  Because we see these changes happening already.

• 25:52Dr. Mary Claire Haver?

  I think it'd be prophylactic, like...

• 25:54Speaker 00

  Why are we waiting for things to happen and then trying to kind of patch it? This needs to be preventative and proactive and early.

• 26:01Dr. Mary Claire Haver?

  So in the same study, 40% of the women with nocturia, so getting up at night to pee, had no other urinary symptom at all. They didn't itch, they didn't burn, they didn't anything. So if a clinician only asks, "Do you leak?", that woman gets missed entirely. So what, what should we be asking? So a woman listening hears this. What should she be telling her clinician? So if we know the normal frequency to pee is every two to four hours during the day, and zero to two times at night, two times at night, normal, a physician should be asking, not just, "Do you have leakage?", but, "How many times are you peeing during the day? How many times are you waking at night to pee? Do you have a hard time starting your urinary stream? Do you feel like you empty your bladder completely?

• 26:46Dr. Mary Claire Haver?

  Do you have a splayed stream or starting or stopping of your stream? Does it burn when you urinate?" We need to go through all of the symptoms that are associated with genital urinary syndrome of menopause and pelvic floor dysfunction to really get a clear picture of what's going on. And it's not just leakage. Is there a place that a listener, or someone watching on YouTube, can find this list of questions to like, have it like, to fill out and take to their doctor?

• 27:11Speaker 00

  In my book.

• 27:12Dr. Mary Claire Haver?

  Oh. So I did learn these, but I want our listeners to really understand. What is the difference between stress leakage and urgency leakage?

• 27:23Speaker 00

  So stress leakage or stress incontinence is when there's an external pressure down on your pelvic organs and your pelvic floor muscles, and your muscles are not strong enough or responsive enough to hold in urine. So you have a cough, a sneeze, a jump, and your urinary sphincter isn't closing quickly enough or sufficiently enough to prevent leakage from your bladder. That's stress incontinence.

• 27:45Dr. Mary Claire Haver?

  So that's an anatomical problem.

• 27:47Speaker 00

  That's an anatomical problem. Urgent incontinence is when there's a sudden urge to urinate. And this could be triggered by washing your hands and hearing running water. Or, we often hear the key-in-the-door syndrome, where someone's pulling up to the house and opening the door, and all of a sudden, an urge comes on. And their bladder has these uncontrolled contractions, and they're not able to suppress that urge, and they have urgency or leakage on the way to the bathroom with the urge. So there's no predisposing mechanical event with urgent incontinence. It's just urgency that's happening.

• 28:17Dr. Mary Claire Haver?

  It's a neurological problem.

• 28:18Speaker 00

  Correct.

• 28:19Dr. Mary Claire Haver?

  How do we treat this?

• 28:21Speaker 00

  Well, both of them, it's comprehensive. And so if it's a stress incontinence issue, we need to work on improving support, right? So this is where the pelvic floor training comes in.

• 28:30Dr. Mary Claire Haver?

  Okay, do you know what I was told in residency?

• 28:32Speaker 00

  What was that?

• 28:32Dr. Mary Claire Haver?

  Surgery or Kegels versus medication. You know, so urge, we treat with medicine to relax the bladder. And then, for the anatomic problem, we restore the anatomy, or we teach them to have stronger muscles with Kegels. That's it.

• 28:46Speaker 00

  And what do we know about those? Neither of them have long-term effectiveness. And there's an intermediate, and it can be with both of those. You can have medication and pelvic floor muscle training. You can have surgery and pelvic floor muscle training.

• 28:58Dr. Mary Claire Haver?

  And you can have stress and urge at the same time.

• 28:59Speaker 00

  Mixed incontinence is actually more common, the combination of stress and urge. But for both of these, for postmenopausal women, it's the declining estrogen levels that weaken the pelvic floor muscles and the urethral tissues, but it also causes more irritation to the bladder. So making sure that you're getting that local topical estrogen to those tissues is gonna be important along with the pelvic floor training.

• 29:22Dr. Mary Claire Haver?

  So let's go back to this woman who's getting up. So she, she's three to five times at night, because, you know, we have to not be normal. Okay, even though I think more than once is outrageous.

• 29:32Speaker 00

  Exhausting.

• 29:33Dr. Mary Claire Haver?

  Is gonna affect her long-term health. And, but like, walk her through your whole protocol.

• 29:40Speaker 00

  So I think one of the first things we mentioned is her hydration. Are you cutting back your fluids, and that actually is causing more concentrated urine and putting you at risk for urinary tract infection? Hydration is key to pelvic floor health. So I want you drinking enough water where your urine is almost clear, but not that you're totally busting your bladder. We all have these emotional support water bottles that we are carrying around, but if you're over-hydrating, that's gonna be an issue. I tell women to front-load their fluids, to try to get the majority of their fluids in the first half of their day, to decrease fluid intake two hours before bedtime. Because it takes about 60 minutes for things to cycle through to your bladder. So you drink a little water, and then you should be done. To avoid bladder irritants right before bed, so that includes caffeinated drinks,

• 30:22Speaker 00

  carbonated drinks, alcohol, citrus foods or juices.

• 30:27Dr. Mary Claire Haver?

  Acidic.

• 30:27Speaker 00

  Acidic foods or juices, those can be irritating to the bladder. So minimize those beforehand. And then also, when you pee, make sure that you're peeing properly, which means you sit down.

• 30:38Dr. Mary Claire Haver?

  Does that mean?

• 30:39Speaker 00

  Oh, there's a proper way to pee, Mary Claire.

• 30:42Dr. Mary Claire Haver?

  Wait, what?

• 30:43Speaker 00

  Yes. Oh, my goodness. So, okay, let me finish this and then we'll get to that one. But she needs to make sure that she's relaxing, not pushing her pee out, that she wipes. I also recommend what's called double voiding. If you feel like you don't empty completely, so then you stand up, sit down again, wipe, you know, see if anything more comes out, wipe, and then you walk away. And then you're ensure that your bladder is empty enough. Your bladder is never completely empty. There's always a little urine in there. But if you lay back down in bed and you're like, oh, I feel like I have to go again, you know you've just emptied your bladder. So take some deep breaths, distract yourself. Even sometimes doing some pelvic floor contractions can quiet the urge back down to help you get back to sleep.

• 31:23Dr. Mary Claire Haver?

  Okay.

• 31:23Speaker 00

  What is the NAC? It's one of my favorite tools that I think women need to know. The NAC is a pelvic floor muscle contraction before a cough or a sneeze. So I always say squeeze before you sneeze or kegel before you cough. Those are those mechanical events that put pressure on the pelvic floor. And if you contract your pelvic floor muscles before then, you can actually prevent leakage. And so we want to train that reflex to come back. We actually have it initially and it fades over time or after birth or with aging. I want you to train your pelvic floor to contract before a cough or a sneeze to see if it will prevent leakage. If it doesn't initially, that's fine. You keep using that habit and as your pelvic floor muscles get stronger, it will help

• 32:08Speaker 00

  you prevent leakage.

• 32:09Dr. Mary Claire Haver?

  Okay. You tell a woman to, and I, I thought about this last night because I'm staying in a hotel, you know, we're in New York. And I made sure the path to the bathroom was clear. I don't want to trip. And I, my daughter was sleeping with me. I didn't want to wake her up by putting the lights on to go to the bathroom. Of course, I had to go once last night. And so, but why do you say that? Why clear that path?

• 32:30Speaker 00

  It's something we don't think about. And as physical therapists, we are not just focused on symptom resolution. We're focused on keeping you safe and healthy, even if you are experiencing a symptom. So for a post-menopausal woman who's waking frequently at night to pee, she also has a higher risk of osteoporosis because we know estrogen deprivation increases, decreases bone density.

• 32:53Dr. Mary Claire Haver?

  Yeah.

• 32:54Speaker 00

  And so she's at a higher risk of a fracture if she falls. One in two women will have an osteoporotic fracture post-menopausally. And so if she has a fall at night, walking to the bathroom in the dark, rushing with the urge to pee, that could cause a different sequelae of symptoms than just leakage. It could be a fracture that impairs her quality of life, results in a surgery, you know, and she could end up in a home. There's a lot of really significant impacts from a fracture and it's as simple as we need to clear that pathway. So some of the tips that I tell women are sleep on the side of the bed that's closest to the bathroom.

• 33:29Dr. Mary Claire Haver?

  Do that.

• 33:30Speaker 00

  Good. Make sure there's nightlights or well-lit pathways along the way. No rugs.

• 33:35Dr. Mary Claire Haver?

  No rugs.

• 33:36Speaker 00

  No bags, no stools along the way. If the bathroom is too far for you to get, you could even consider getting a bedside commode next to your bed so that you don't have to do the walk. And then I even have some patients who have told me they take a washcloth to hold it up against the vulva and vagina and hold pressure there so that if they do leak, they're not worried about dripping it on the floor. These are real changes that women can make that are going to have a big impact if we can help prevent falls.

• 34:05Dr. Mary Claire Haver?

  Can we talk about one of the most frustrating things about sleep in midlife? Waking up hot. You know the feeling. You're tossing and turning, kicking off the covers, flipping your pillow over, just trying to find a cool spot so you can get back to sleep. But here's something we don't usually think about. Your bedding can make a difference. That's where SiJoo comes in. Their Airiweight Eucalyptus Sheet Set is made from Tensile Liocell and it's incredibly soft, lightweight, and breathable. And these sheets absorb 70% more moisture than standard cotton, making them a great option if overheating or night sweats are getting in the way of your sleep.

• 34:48Dr. Mary Claire Haver?

  They're also Ecotec Class 1 Certified, Safe for Sensitive Skin, and HSA/FSA Eligible. And for an even cooler sleep setup, pair them with SiJoo's Adjustable Flex Cool Memory Foam Pillow. So if you're ready to make your bed less of a battle zone and more of a sanctuary, check out SiJoo's Airiweight Eucalyptus Sheet Set and Flex Cool Memory Foam Pillow. Go to sijohome.com and use the code UNPAUSED to get 20% off your first order. That's S-I-J-O-H-O-M-E.com and use code UNPAUSED for 20% off at checkout. This episode is brought to you by Whoop, the wearable health and fitness coach that

• 35:31Dr. Mary Claire Haver?

  gives you personalized insights into your sleep, recovery, strain, and overall health so you can empower your day. Whoop keeps things intentional by staying screen-free. It won't buzz to you to hit a step count, but rather works alongside a companion app to deliver clear, actionable physiological data. With membership tiers like Whoop 1 for everyday performance, Whoop Peak for long-term wellness, and Whoop Life for medical-grade insights, there's a fit for every goal. Lately, I've been spending a lot of time in Colorado, hiking and getting outside whenever I can. And with how much I travel for work and how busy my schedule can get, I'm always looking for ways to better understand how my body is responding to everything I'm asking of it.

• 36:16Dr. Mary Claire Haver?

  That's where I think something like Whoop 5.0 Wearable could be really helpful. It could give me insights into my sleep, recovery, and strain, whether I'm hiking in Colorado, traveling for work, or simply trying to keep up with a busy week. It can help me recognize when I have the energy to push myself and when my body might be telling me it's time to slow down and prioritize recovery. To learn more, head to whoop.com.

• 36:44Dr. Mary Claire Haver?

  So recurrent UTIs are killing women.

• 36:49Speaker 00

  Yeah.

• 36:51Dr. Mary Claire Haver?

  And 50% of them are preventable, we know now, with prophylactic vaginal estrogen. So how does a woman know if it's actually an infection?

• 37:03Speaker 00

  Well, you have to get a urine culture or a urinalysis. You cannot go based on symptoms. And unfortunately, women have been given antibiotics for what seems like a UTI, which it's not. And so we have to get a culture or urinalysis to make sure that it is an active infection. And if it's not, then we need to be treating those symptoms. Again, to your point, topical vaginal estrogen. And how is their bladder functioning? Are they emptying well? Do they have a prolapse where urine's pocketing in there and it's not getting out completely? You know, are they dehydrated because they have leakage and they're not getting enough fluid intake? We really, again, need to dig deeper as to what be, could be contributing to that UTI if it's not just a pH imbalance or lack of estrogen.

• 37:46Dr. Mary Claire Haver?

  So the AUA, American Urological Association Guidelines are now, you know, we have brand new guidelines for general urinary syndrome of menopause, or general urinary syndrome of being a woman. You know, anytime we have low estrogen, we're nursing, we're on birth control suppression, you know, so it's not just post-menopausal for our younger patients who are listening. Like, I saw this all the time when my patients were nursing.

• 38:09Speaker 00

  Yeah.

• 38:09Dr. Mary Claire Haver?

  Because their estrogen levels were tanked.

• 38:10Speaker 00

  Exactly.

• 38:11Dr. Mary Claire Haver?

  Because they were ovulating because of the oxytocin for, you know, breastfeeding, which is the way nature intended it, right? They want to space our children out a couple of years when we're nursing. So however, in the post-menopausal patients with recurrent UTIs, in 1993, they did the study. And they did vaginal estrogen for this group, no vaginal estrogen for the other. And it showed 0.5 infections per patient year on estrogen versus 5.9 on placebo.

• 38:42Speaker 00

  Insane.

• 38:43Dr. Mary Claire Haver?

  It's insane.

• 38:43Speaker 00

  It's insane. And this is where, why aren't we doing this prophylactically? Why isn't this preventive?

• 38:48Dr. Mary Claire Haver?

  I am.

• 38:48Speaker 00

  Yeah. I know. And I'm telling every patient who's vulva I see, I'm like, you need to be on topical vaginal estrogen and you need to be on topical vaginal estrogen.

• 38:55Dr. Mary Claire Haver?

  Just go to Epic and put it in a note.

• 38:56Speaker 00

  So it's one of those things that we should not wait until it gets to that point where it's a life-saving intervention. It should be well before then. And this is where I think we can really change the course of the second half of women's lives where, and also it's a cost savings.

• 39:12Dr. Mary Claire Haver?

  So the orthopedic surgeons, I've interviewed a couple, Vonda and Jocelyn Whitstein, and they both felt very strongly clinically what they see. The percentage of women who show up in the ER with a fractured hip with a concurrent UTI.

• 39:28Speaker 00

  Wow.

• 39:29Dr. Mary Claire Haver?

  Is over 60%.

• 39:31Speaker 00

  Wow.

• 39:31Dr. Mary Claire Haver?

  And they said... They wonder how much of this was getting up to pee in the middle of the night, tripping, falling, or delirium from early sepsis. And they fall. And so my own mother's hip fracture, sure enough, she had a UTI at the time of her fall. And she never walked again, you know, and it's just the like worst case scenario for my mom.

• 39:54Speaker 00

  It's heartbreaking.

• 39:55Dr. Mary Claire Haver?

  It's heartbreaking. And I just think how much of this could have been prevented where she would have had a better quality of life at the end here.

• 40:02Speaker 00

  A lot. I mean, and this is the thing, you know, I started being more vocal about pelvic floor therapy 10 years ago. I started this Instagram account because the first 10 years of my career, I felt like I'm just doing damage control. Like I'm seeing all of these women come in and they've had symptoms for years. And maybe they finally got to the right doctor who said, oh, you should try this after they failed everything else. And then the first thing that they said was, why didn't anybody tell me about this sooner?

• 40:27Dr. Mary Claire Haver?

  Yeah.

• 40:27Speaker 00

  Like, why wasn't this integrated sooner? And so I think that we need to really, and then I started being more vocal about it because I said, women need this because we can prevent a lot of these issues from getting to that really detrimental point.

• 40:39Dr. Mary Claire Haver?

  So every time I post about it on social, about vaginal estrogen for recurrent UTIs and GSM, the amount of comments floors me. One, where women are advocating for their mothers and talking about these miserable courses that they've had. And finally, someone gave them vaginal estrogen and it changed their life. No more UTIs or dramatic reduction and her quality of life is so much better, or it's happening to the patient themselves. And I think we just need to keep spreading awareness. I know you don't prescribe it as a physical therapist, but as prescribing physician, just it's only a couple of times a week.

• 41:14Speaker 00

  Yeah.

• 41:14Dr. Mary Claire Haver?

  And now there was an awesome study that just came out. We don't have to use the applicator and put it in the vagina for it to work for UTIs. You literally just put it on your finger and get up there and rotaruder, put it on the urethra, go down the labia.

• 41:26Speaker 00

  Yeah.

• 41:27Dr. Mary Claire Haver?

  Get some in the vagina and you're good to go.

• 41:28Speaker 00

  Right.

• 41:29Dr. Mary Claire Haver?

  Twice a week. So when I change my patch, I use my vaginal estrogen.

• 41:33Speaker 00

  Yeah.

• 41:33Dr. Mary Claire Haver?

  It's amazing.

• 41:34Speaker 00

  It's amazing. And I think people don't, we just have to walk them through what to do.

• 41:38Dr. Mary Claire Haver?

  Yeah.

• 41:38Speaker 00

  You can't just say, go use this and then.

• 41:40Dr. Mary Claire Haver?

  No, no, no, no. I like pull it out at the clinic visit. I show them the tube. I show them, put it, you know, I demonstrate like what it looks like on your finger. And I show them what the applicator is, tell them they can throw that away if they don't like it, you know, they're, you only get one. It's hard to clean. It gets messy. And for some women, their.

• 41:56Speaker 00

  Tissues are so sensitive.

• 41:58Dr. Mary Claire Haver?

  So sensitive that getting that applicator is so painful.

• 42:01Speaker 00

  Right.

• 42:02Dr. Mary Claire Haver?

  And for them. So we're on the same page here.

• 42:04Speaker 00

  Okay.

• 42:05Dr. Mary Claire Haver?

  Let's talk about prolapse where nobody wants to talk about prolapse, but it is 50% of women at least, right?

• 42:12Speaker 00

  Yeah, it is. And so let's talk about what prolapse is.

• 42:15Dr. Mary Claire Haver?

  Yeah.

• 42:15Speaker 00

  So prolapse is when this hammock of muscles, your pelvic floor muscles are not supporting your organs as well. And so you have your bladder that rests inside of that hammock.

• 42:26Dr. Mary Claire Haver?

  Right here.

• 42:26Speaker 00

  Yep. You got it. Your bladder, your uterus, your rectum all rest inside of that hammock.

• 42:30Dr. Mary Claire Haver?

  Right in here.

• 42:32Speaker 00

  So when that hammock gets weak or lengthened, those organs are not going to be supported as well. And they will start to push into the vaginal wall. And so the way that prolapse presents, it can feel like pressure or heaviness in the vagina. It can feel like something's falling out. There can be a vol, a bulge at the opening of the vagina. A lot of women feel like I was in the shower or I was going to the bathroom and I felt a bulge there and it totally freaks them out.

• 42:56Dr. Mary Claire Haver?

  They went to wipe and they felt.

• 42:57Speaker 00

  Exactly. And it typically gets worse at the end of the day in standing or with heavy lifting or straining. So what's important is that we talk about like what caused it, right? But also what can we do about it? A lot of women have prolapse and they don't even know it.

• 43:13Dr. Mary Claire Haver?

  Right. So the data is pretty astounding.

• 43:15Speaker 00

  Yeah.

• 43:15Dr. Mary Claire Haver?

  Only 3% of women report symptomatic prolapse. But on physical exam, somewhere between 40 to 50% have some degree.

• 43:23Speaker 00

  Yeah.

• 43:23Dr. Mary Claire Haver?

  Where's that gap?

• 43:24Speaker 00

  So there's different levels of prolapse. So grade one and two are typically above the vaginal opening or just below it. And then grades three or four, where there's kind of complete protrusion of the tissue out.

• 43:37Dr. Mary Claire Haver?

  Basically coming out of the vagina.

• 43:39Speaker 00

  And the lower third of the vagina has more nerve endings and is more sensitive to touch than the higher portion. So it's not until prolapse hits that lower third of the vagina, do people start feeling it. So if you have a grade one prolapse, you may not know, but not until it gets more severe and it's starting to push towards that vaginal opening, will you start to feel that rubbing irritation, pressure or heaviness? So it's not education. It's really our body isn't telling us that something's wrong until it gets more significant.

• 44:07Dr. Mary Claire Haver?

  Okay. And does it usually start as a stage one? I mean, does it work its way through to the more severe or do you just wake up with complete prolapse?

• 44:15Speaker 00

  No, it definitely starts more stage one. And we see this most often postpartum. So if you have a pregnancy, any pregnancy, not even just a C-section, any pregnancy changes your pelvic floor.

• 44:25Dr. Mary Claire Haver?

  You have a bowling ball in your, in this, in here.

• 44:28Speaker 00

  In this hammock. And so what happens when you have, you know, a watermelon in a hammock? It stretches, it sinks lower and it gets more stretched out. And it doesn't just bounce back after birth, as we know. So pregnancy and then a vaginal birth, having multiple vaginal births, so three or more vaginal births. And there's also a genetic component. All of those things are risk factors for prolapse, along with obesity, smoking, heavy coughing, you know, higher intensity activities. So there's.

• 44:57Dr. Mary Claire Haver?

  Runners.

• 44:58Speaker 00

  Runners. There's some predisposing factors. There's a genetic component and there's a mechanical factor postpartum. And then we hit perimenopause and postmenopause. Where now we have lower estrogen levels. Estrogen produces collagen, which we know, we talk about for our face and our hair. But it also creates that collagen that is the supportive tissue in the pelvic floor. So when we don't have that collagen for support, prolapse is going to be more likely to happen. So it's progressive over time.

• 45:24Dr. Mary Claire Haver?

  You have this great analogy when we talk about prolapse, the boat, the docks, the rope and the water.

• 45:30Speaker 00

  Yeah.

• 45:31Dr. Mary Claire Haver?

  Explain this to our listeners.

• 45:32Speaker 00

  So what happens is when we think about the dock, the bow, the anchor, all of these things. So your pelvic floor muscles against it like a hammock. So think of that like the water, right? Is that's the water. And then you have the boat, which is your pelvic organs that are kind of sitting in that water and they're buoyed up by that water.

• 45:51Dr. Mary Claire Haver?

  Okay.

• 45:52Speaker 00

  And then you have the ropes, which we tie from the boat to the dock, right? That's your pelvic ligaments. So you have ligaments supporting the organs. You have the water supporting the organs from below. If those ligaments get stretched, that boat's going to kind of sink a little bit more into the water, right? So, but you still have the water there to support it. If that water gets lower, that water level gets lower, so your pelvic floor muscles get weaker. It puts more strain on those ligaments and that has to work over time. So a deficit in either one of these can cause pelvic organ prolapse where those organs are not as well supported by the water or the ropes of the boat, and they start to sink down and push into the vaginal canal. But what's interesting is the surgeries we do just replace the rope.

• 46:36Speaker 00

  They just tack that bladder up or tack the uterus up so it's not prolapsed anymore. But we don't improve the water level. So we have to do the pelvic floor training to also help lift the boat from below.

• 46:47Dr. Mary Claire Haver?

  Thinking of the sacro spinus ligament fixation. I only watched those. I didn't do those.

• 46:53Dr. Mary Claire Haver?

  And yeah, you're not fixing the actual pelvic floor itself.

• 46:56Speaker 00

  Correct.

• 46:57Dr. Mary Claire Haver?

  The FDA ordered transvaginal mesh for prolapse. Now I was training when we were using a lot of mesh early on, off the market in April 2019. There was a white paper that started it, found that roughly 10% of women had mesh erosion within 12 months. I've seen it.

• 47:19Speaker 00

  Yeah.

• 47:19Dr. Mary Claire Haver?

  It is really scary. And then longer follow-up, put exposure at 11 to 18% in three to five years. So what does a woman who has a mesh, you know, placed years ago in place and in good faith, right? We didn't know the outcomes yet.

• 47:34Dr. Mary Claire Haver?

  What does she need to know?

• 47:35Speaker 00

  If someone has had this mesh procedure for prolapse, because there was a difference between having it for stress incontinence or urethral slings. So for prolapse specifically, if she is not symptomatic, she's okay. She does not necessarily have to have this removed. Symptoms to look out for would be pelvic pain, painful sex. There could actually be perforations into the organs. And I've seen women have fistulas, which is a canal that burrows between the vagina and the rectum, where you'll actually start having stool come through the vaginal opening. So the thing about the vaginal mesh was I was treating patients at UT Southwestern in Dallas for 10 years. And we had an incredible pelvic rehab program. And one of the surgeons was one of the top surgeons in Texas who was treating these mesh revisions.

• 48:19Speaker 00

  And so he would see the patients, do the mesh revisions, try to remove everything he could and then send them to rehab. And these women were crushed. They were in tears. They were in pain. Some of them had to quit work. Some of them could not care for their children. Some of their relationships were affected. And it was heart wrenching. And I kept thinking, what if we had never done these surgeries? What if they had had rehab or pessaries or something else? So it didn't get to this point where now they have this severe pain that they may have for the rest of their lives because this surgery went awry. And it was heartbreaking. And this is really where I said, we need to start championing pelvic rehab sooner.

• 49:02Speaker 00

  Because we're letting it get to this point where, to your point, Kegels or surgery, where surgery was the only option.

• 49:08Dr. Mary Claire Haver?

  Or live with it.

• 49:09Speaker 00

  Or live with it. And there's so much we could do. And I apologize because some of these images are graphic, but there were women who the mesh was seeping into their sacrum and we could pull out threads of the mesh through their buttocks. There were women who, they said their partners felt the mesh during sexual intercourse. And it felt like it was scraping their partners.

• 49:29Dr. Mary Claire Haver?

  Yes. It rode through the wall of the vagina.

• 49:31Speaker 00

  Literally fibers are roding through the wall of the vagina. And it was, it was awful. And these women did not deserve this.

• 49:39Dr. Mary Claire Haver?

  So talk to me about the difference between urethral prolapse and vaginal prolapse, as we're talking about prolapse.

• 49:47Speaker 00

  So prolapse, there's a couple of different types. So if we think about, the vagina is really a canal. So think of it like a canal on the inside of the pelvis.

• 49:54Dr. Mary Claire Haver?

  It's a tube.

• 49:55Speaker 00

  It's a tube. So you have the bladder that sits in the front part of the vagina.

• 49:59Dr. Mary Claire Haver?

  The top.

• 49:59Speaker 00

  Yep. And the rectum that sits posterior or towards the back or bottom. And at the very top of the vagina, you have the cervix, which is the opening to the uterus. So I always think of it like a tent. You've got the pitch of the tent and at the very top is the uterus and the cervix. And you've got the bladder towards the front top and the rectum towards the back top. What happens is that whatever organ is prolapsing is pushing into that vaginal wall. So a urethral prolapse or bladder prolapse will be in the front part of the vaginal wall. So if you're looking at this at the

• 50:27Dr. Mary Claire Haver?

  So I always have the gynecologist's viewpoint.

• 50:29Speaker 00

  Exactly.

• 50:30Dr. Mary Claire Haver?

  So like, I'm looking at the pelvis this way and she's laying down on her back.

• 50:33Speaker 00

  So you would see the top part of the vagina protruding out.

• 50:36Dr. Mary Claire Haver?

  Mm-hmm.

• 50:36Speaker 00

  For the rectum, that would be the back wall, the posterior wall. You'd see that on the back part of the vagina. And then if you feel the cervix or the uterus at the top, then you'll see the top of the vaginal canal. If someone has had a hysterectomy, that vaginal prolapse will be coming from the top. They won't have a cervix or uterus to prolapse. But it can come from any direction.

• 50:56Dr. Mary Claire Haver?

  Anywhere. It can even turn inside out.

• 50:58Speaker 00

  Yes, you can have complete extrusion of these tissues outside of the vagina. And the only, as much as I love pelvic floor therapy, we do have limitations and that is a surgical candidate.

• 51:10Dr. Mary Claire Haver?

  So what should a woman ask before she consents to any prolapse repair?

• 51:15Speaker 00

  I would say, do I have other options? You know, the first thing are, have you been using topical vaginal estrogen? Have you, have you been, have pessaries been discussed with you as an option, which is, we can kind of talk more about that as well. It's an intermediate device to support the pelvic organs and vaginal wall. Have you, do I need to do pelvic floor training before or after? And I would ask about what type of surgery am I having? Are you using mesh? More often now, they don't for prolapse repairs. It's going to be kind of using your native tissue. And then I would say, what are my post-op restrictions? Like, you should not be going back to heavy lifting or straining with bowel movements immediately. And I would absolutely recommend post-rehab pelvic floor

• 51:56Speaker 00

  physical therapy after surgery, just like we do for an ACL or shoulder surgery. You have to rehab after.

• 52:02Dr. Mary Claire Haver?

  What percentage of patients do you think are receiving pelvic floor PT after these surgeries?

• 52:08Speaker 00

  Probably less than 10%.

• 52:10Dr. Mary Claire Haver?

  So where can our audience find you?

• 52:12Speaker 00

  So I am mainly on Instagram as the Vagina Whisperer. I am on TikTok as the Vag Whisperer because TikTok doesn't like the word vagina.

• 52:20Dr. Mary Claire Haver?

  True.

• 52:22Speaker 00

  My website is thevaginawhisperer.com. I have an app called the V-Hive, which has at-home pelvic floor training, which everyone can get a free trial. And they can test it out, like what does a pelvic floor workout look like? And you can also find my book, Floor it, at anywhere you'd like to buy books.

• 52:36Dr. Mary Claire Haver?

  Awesome. Thank you so much for joining us on UnPaused today.

• 52:40Speaker 00

  Thanks for having me.

• 52:43Dr. Mary Claire Haver?

  You can find full episodes of UnPaused on YouTube at Dr. Mary Claire. Also, you can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepauselife.com. UnPaused is presented by Odyssey in conjunction with Good Roommate Media and Long Wave Digital.