When you’re an OB-GYN like Attn: Grace medical advisor Dr. Barbara Frank, answering questions (lots of questions) is all in a day’s work, and she’s heard everything! Today, she’s tackling every stage of womanhood, the finer points of dealing with leaks, and why Kegels are still the best and easiest way to keep your pelvic floor strong. Let’s get into it!
Question: I’m younger – I have not had children yet and am far away from menopause – but I want to set my body up for later in life? What can I do now to combat potential urinary incontinence later?
Dr. Frank: What a wonderful question. I think that in years past, this was hush, hush. We didn't talk about our incontinence. We definitely didn't talk about vaginas and vulva and periods. That was not mainstream to talk about.
The best thing you can do now is to set up good habits and ask questions! Before you have any problems with incontinence, it's important to learn what your pelvic floor is.
Think of your pelvic floor as a hammock of muscles that's holding in everything: your organs, including your bladder, your uterus and your intestines, your rectum. That pelvic floor needs exercise the same way as any other muscle, or it can become weak over time. Alternatively, it also can become too tight and have spasms.
Knowing where that pelvic floor is, either by practicing a Kegel or having your gynecologist help show you, is just step one. The pelvic floor is the hammock of your entire insides. Over time, gravity, having babies, being overweight all can increase the laxity of your pelvic floor and increase your risk of incontinence.
The other thing to make sure you start to do early is taking care of the skin around your vulva and vagina. Avoid harsh soaps and choose clean products. That skin is delicate!
There is a lot of data about drinking a lot of fluids and staying hydrated, you don’t need to overdo it. 64 ounces of fluids per day is usually enough. So sometimes incontinence comes from drinking too much. Limiting caffeine to once daily is also a good idea if you start to have any problems with your bladder.
Question: I’ve been seeing so much news about the horrible materials in period care products? Are incontinence products the same? How do I know which ones are safe and which do you recommend?
Dr. Frank: You're right. There are so many products on the market and it is true that we have to be really cautious about what we put on our skin. I say we should treat our vulvar skin the same way that we treat our baby's bottom!
We need to think about what we put on our most sensitive areas, just like we think about the food we put into our bodies. Hygiene products across the board are being looked at under a microscope regarding what is in them and what is safe to use.
When you think you’re buying simple cotton tampons or incontinence pads, you may not think about all the ingredients, but you should! The things that we really want to avoid are things that are caustic or inflammatory to the tissue like fragrances, petroleum jelly, parabens, PFAS (AKA forever chemicals), bleaches, synthetic dyes. You might have to go searching on their website or even reach out to the company directly to see what ingredients they use and where they source their products from.
Aside from being potentially damaging to the skin, some of these materials are what’s called endocrine disruptors: chemicals that can disrupt our normal hormonal balance. We need to keep an eye out for those and make sure that the products that we're buying are saying and proving that they are clean.
So at Attn: Grace, you can see that the products don't include toxic materials or chemicals. You can look at the Absolutely Nots page where there is a long list of what is not in their products and why.
And finally, the most important thing to look at when you are looking at pads is making sure that you're staying dry and that the product is wicking away the moisture from that top layer, so you're not irritating the skin more.
Question: Do hormonal changes during my menstrual cycle impact incontinence? How can I support those symptoms throughout the various stages of my cycle?
Dr. Frank: The normal cycle, if you are not getting estrogen and progesterone from an external source like a birth control pill, a patch, the NuvaRing, the shot or a progesterone-secreting IUD (like Mirena) then you will have normal fluctuations of hormones during your cycle.
So when your period comes, your hormones are low. Estrogen and progesterone start to rise as you start to ovulate, then they peak, and if you don't become pregnant, then they drop and you get the symptoms associated with PMS from those hormonal changes.
Typically, if you're a younger menstruating woman, you're not going to notice too much incontinence or issues surrounding your period. It's more when you become perimenopausal and menopausal where the estrogen baseline levels are lower and when they're at their lowest, which would be during menstruation and slightly afterwards, you might notice some changes in the skin or tissue around around the vagina and the urethra, which can increase incontinence and irritation.
If you are premenopausal and your estrogen levels are normal, this shouldn't be an issue, unless you have other habits around your period. Maybe you are eating more chocolate or having more caffeine, which are both bladder irritants. Maybe you're out with your friends having a couple of glasses of wine, which relaxes the bladder. That could lead to incontinence
In a woman with normal estrogen levels, hormones alone should not lead to incontinence related to your menstrual cycle.
Question: How does incontinence show up during perimenopause? What can I do to prepare beforehand and during it to support it?
Dr. Frank: The word perimenopause is very vague, so let's define it. First, perimenopause is defined by the 10-year period before menopause. The definition of menopause is cessation of periods or no menses for one year. The average age of a woman in the US going through menopause is 51. So, perimenopause starts in your forties.
Most of the connection to incontinence is due to “simple” things: as you age, gravity takes over and your pelvic floor muscles start to relax and there's an increased risk of incontinence. Maybe you’ve had children, and your pelvic floor is weaker due to that.
At this point, we need to keep an eye on all these other healthy habits that we discussed before. A healthy weight and a good exercise regimen both can help support the pelvic floor. Work on your Kegel exercises by squeezing in the muscles around the pelvic floor, hold and count to five, then release. Do three sets of ten and then three more sets at a quicker pace.
If you're not sure if you're doing a Kegel correctly, you can ask your provider and you can also go see pelvic floor physical therapy who do a quite invasive exam, an internal exam, what we call a bimanual exam and teach you exactly where your pelvic floor muscles are.
I know this sounds intense and it does sound time-consuming, but this is a great way to prevent weakness in the pelvic floor.
Question: I’m in my 60s and feel like I’ve missed my chance to do anything about my urinary incontinence. Am I a lost cause or is there anything I can start doing now that will actually make an impact?
Dr. Frank: I have good news for you: It's never too late to start carrying or recognizing your pelvic floor.
Let's go back to basics and talk a little bit about incontinence. There are two basic kinds of incontinence: stress urinary incontinence and overactive bladder.
Stress urinary incontinence is anatomical, meaning there is something different about the pelvic floor, either after child-bearing, injuries to your pelvic floor, or body weight. Another cause could be prolapse, where your organs are out of place, like the bladder or the uterus, and that changes the anatomy of the pelvic floor. Any of these changes can increase your risk of incontinence or leaks.
Overactive bladder has to do with the smooth muscle of the bladder. You get the feeling that you really have to go, and you leak a little because your bladder is in a spasm. Sometimes that happens when the bladder can't fill the full capacity or you feel like you haven't emptied your bladder all the way.
If you're suffering from incontinence the first step is to figure out exactly what the problem is. That might mean talking to your health care provider or keeping a voiding diary to track what’s happening.
In a voiding diary, you write down everything you drink and every time you void throughout the day to see if there's any patterns.
How often are you urinating? How much are you drinking? Are you getting up at night to go? Do you feel like you've fully emptied your bladder? All of this information can tell you a lot.
Maybe you learn that you’re going to the bathroom frequently during the day–after coffee, every time before you leave the house, just to be sure that we're empty. If that’s the case, your bladder is not getting used to the stretch and might feel full at a smaller volume. Your diary will show that and then you can make a goal to go at least three hours, or ideally four between voids to increase the capacity of your bladder.
Depending on what the cause of your incontinence is, there is a lot you can do still. Kegels, pelvic floor physical therapy, something called a pessary could be used if you have issues with prolapse. There are also surgeries that we can do, such as a bladder sling, that help fix the anatomy. It's never too late to get started on solutions to this very common problem.
Question: What are the most important questions I should be asking my doctor about urinary incontinence as I get older? I don’t know where to begin!
Dr. Frank: The fact that you're asking this question shows that you are thinking about this problem! That’s great and an improvement over just putting up with it. It’s so great to see the conversation changing so women don’t have to live with this.
You could ask your doctor to confirm that you are doing a Kegel exercise correctly, or to help you better identify your pelvic floor. If you’re having some leaks, there are fancy bladder tests to see if you have voiding dysfunction. The most important thing you can do is just listen to your body, know your body, and speak openly with your doctor. Ask us anything!
Question: Can you explain why it is so common to get UTIs with urinary incontinence?
Dr. Frank: Well, there's two reasons. One is simply that urinary incontinence increases as you age, and estrogen levels when you're postmenopausal.
That’s a problem because estrogen increases the tension of your pelvic floor. It helps with collagen and strength and elasticity of the pelvic floor, so a decrease diminishes all of those things. Also, estrogen is really great at protecting the skin of the vulva, vagina, and specifically around the urethra. As that skin becomes more fragile, it is more likely to have breakdown of the skin, and then bacteria can then get up into the bladder and cause urinary tract infections.
The second thing is that with urinary incontinence, you're likely wearing a product like a pad or underwear that is getting wet and moist. Wet and moistness are also irritants to the skin. When the skin is irritated, it then increases your risk of bacteria formation and again, the bacteria can travel to the bladder.
To mitigate this risk, make sure you're wearing products that are really good at wicking away moisture so that your skin is not continually being touched by a wet pad. You can also use a layer of protectant like a barrier cream or ointment to protect fragile skin from running, friction, and irritation from any pad or incontinence product.
Picking good products, protecting your skin and staying dry will all decrease your risk of urinary tract infections.
Thanks so much for your insights, Dr. Frank! Didn’t have a chance to ask your question? Save it for our next installment.