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Nov 12, 2014

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Research published last year in Archives of Gynecology and Obstetrics describes the benefits of "triple therapy" for symptoms of urogenital aging in postmenopausal women. The triple therapy included pelvic floor rehabilitation, intravaginal estradiol, and Lactobacillus acidophili on symptoms of urogenital atrophy, urinary tract infections (UTI's), and stress urinary incontinence (SUI) in postmenopausal women. 136 women with postmenopausal urogenital aging symptoms were divided into two groups of 68 women. Group 1 received intravaginal treatment of combined estriol (30 mcg) and Lactobacillus acidophili (50 mg) and pelvic floor rehabilitation. Group 2 received intravaginal estriol (1 mg) plus pelvic floor rehabilitation. The intravaginal treatment was applied once/day for 2 weeks and then twice/week up to 6 months.

 

Symptoms of urogenital aging listed by the authors include lower urinary tract issues (urinary frequency and urgency, nocturne, dysuria, recurrent UTI's, and urinary incontinence (UI)), and vaginal or vulval symptoms (vaginal dryness, itching, burning, and dyspareunia.) The connection between the microbiota Lactobacillus acidophili and vaginal health is described in the article involves the proliferation of Lactobacillus acidophili that is stimulated by estrogen. The microbiota then is reproduced in the vaginal epithelium, reduces pH, and prevents colonization of pathogens that can lead to UTI's. The pelvic floor muscle training was completed "…as explained by Castro et al…" in reference to the 2008 study assessing the efficacy of pelvic floor muscle training, vaginal cones, electrical stimulation, and no active treatment. The pelvic floor training in the Castro study included group sessions of pelvic floor muscle contractions as follows: 10 repetitions of 5 seconds contract, 5 seconds relax; 20 repetitions of 2 seconds contract, 2 seconds relax; 20 repetitions of 1 second contract, 1 second relax; 5 repetitions of 10 seconds contract, 10 seconds relax; and 5 simulated cough with strong contraction with 1 minute rest in between.

 

In the study, the authors assessed outcomes of urogenital symptoms in women aged 55-70 including urine cultures, colposcopic and urethral cytologic findings, urethral pressure profiles, and urethro-cystometry before and 6 months after intervention. Results included that both groups demonstrated significant improvements in symptoms and signs of urogenital atrophy , and 76% of the triple therapy group (Group 1) reported improvement in incontinence versus 41% of Group 2. Subjects in the triple therapy group also were observed to have significant improvements in colposcopic findings, urethral pressure and closure, and in abdominal pressure transmission ratio to the proximal urethra. The study concludes that combination therapy of estriol, Lactobacillus acidophili, and pelvic floor rehabilitation should be considered first-line treatment for postmenopausal symptoms of urogenital aging. To learn more about menopausal evaluation and interventions, check out faculty member Michelle Lyons' new course on Menopause: A Rehabilitation Approach. The next opportunity to take this course is in February in Orlando.


Oct 22, 2014

How long do hot flashes last in a woman's life? One recent study asked this question by following 255 women from premenopause to natural menopause. The authors found that moderate to severe symptoms of hot flashes continued on average 5 years after the date of the woman's last period. Unfortunately, up to 1/3 of the women continued to report hot flashes 10 or more years after menopause. Results also found that risks for hot flashes were higher in women who were African-American or in obese, white women. Higher education level was found to be protective against hot flashes.

 

The Mayo clinic states that while the exact cause of hot flashes is not known, there are several factors that may influence their occurrence. Changes in reproductive hormones in addition to hypothalamic shifts create a sensitivity to even slight changes in temperature. Women can experience a wide range of menopausal symptoms, with hot flashes ranging from sudden feelings of warmth that occur a couple times per day to profuse sweating that can occur up to one time per hour.

 

Menopause.org is a helpful resource for our patients, and lifestyle changes are offered such as avoiding stress, breathing techniques, and creating strategies to maintain body temperature within a limited range. Hormonal treatment and non-hormonal options are also described on this site, and while certain hormonal options may be contraindicated for some patients, there are therapies such as sleeping medications that may improve quality of life for a woman who is suffering significant sleep disruption. Decisions to utilize hormonal drug therapy may depend on many factors, such as benefits to risk ratios, if the patient has her uterus, and age of the patient. Many nonprescription options are also available, with conflicting or little evidence to support many of the claims. Regardless of the remedy that a patient may take for her menopausal symptoms, keep in mind that all medications or supplements should be reported to the physician and/or pharmacist so that drug interactions can be screened. Even herbal supplements can have a negative impact on other drugs that a woman is taking, so she should always fully disclose her medications, supplements (including teas!), creams, and other natural remedies.

 

If you are working with more women in the perimenopausal period, you may have questions about the hormonal changes and effects on rehabilitation. Faculty member Michelle Lyons will offer her new continuing education course called Menopause: A Rehabilitation Approach. At this course she will systemic changes in menopause, bone health, perimenopausal pelvic floor issues, sexual health, weight management, and procedures such as hysterectomy. The next opportunity to take this course is in February in Orlando - what a great time to head to the sunshine!


Sep 24, 2014

This post was written by H&W instructor Michelle Lyons, PT, MISCP. Michelle will be instructing her course "Menopause: A Rehabilitation Approach" in Florida this February.

 

Michelle Lyons

The physiological effects of the decline in circulating estrogen, combined with the aging process, put postmenopausal women at risk of urogynecological dysfunction (Lee 2009). Incontinence, prolapse and sexual dysfunction are common problems, and their symptoms can greatly affect quality of life. Pelvic therapy can offer effective, conservative, and cost effective treatments for these issues.

 

The most significant aetiological factors for the development of prolapse are advancing age and parity (MacLennan et al, 2000). Several studies have investigated tissue metabolism and properties in postmenopausal women with symptoms of prolapse and/or stress urinary incontinence. Links have been identified between these symptoms and alterations in connective tissue and estrogen levels.

 


Mar 02, 2012

The North American Menopause Society (NAMS) has issued a new position statement related to recommendations for hormone therapy (HT) use in women. This topic has been debated intensely over the last decade since the publication of the Women's Health Initiative (WHI) research that was funded by the National Institutes of Health (NIH). Following this research, many women were instructed by their physician to stop taking their hormone therapy medication due to the increased risk of cardiovascular events. For more information about the background of the WHI, please click here.

 

This information is particularly relevant for the pelvic rehabilitation provider as many women in their perimenopausal years will experience pelvic symptoms related to a decline in hormone levels. The updated NAMS guidelines state that estrogen therapy (ET) is "...the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy..." that may include vaginal dryness, pain with penetration, and atrophic vaginitis. Although the guidelines do not recommended hormone therapy for improving libido, use of local estrogen therapy may contribute to improvement in sexual function through improved lubrication, increased blood flow and increased sensation to vaginal tissues. Local estrogen has also been demonstrated to help some women who have overactive bladder or urinary tract infections, however, systemic hormone therapy may worsen symptoms of stress incontinence.

 

There are other important women's health topics in this position statement including potential benefits of hormone therapy for women who have or who are at risk for osteoporosis. The authors conclude that in healthy women ages 50-59 years old the absolute risks of HT are low. Older women who initiate use of HT or who use long-term HT are at higher risk for adverse effects. Successful implementation of hormone therapy for women depends on the route of administration, formulation of the hormones, and timing of the therapy. "Constructing an individual benefit-risk profile is essential..." when creating a plan of care for women according to the authors.

 

Unless it is within your scope of practice to prescribe medications such as hormones, the above choices will be made through patient discussions with the appropriate medical provider. We can alert a physician or medical provider if there is concern about the vaginal tissue health of a woman presenting to the clinic. We can also direct patients to these new guidelines developed by the NAMS group. It is helpful to note that many women do not have a medical provider who is actively managing her hormone issues, and simply asking her about HT can lead her to communicate more effectively with her medical providers.


Oct 15, 2011

In Menopause: The Journal of the North American Menopause Society, an article addressing the effects of menopausal symptoms that affect work is discussed. A cross-sectional sample of 208 Dutch women aged 44 to 60 years were evaluated using the Work Ability Index and the Greene Climacteric Scale. The conclusion of the study is this: "Menopausal symptoms are negatively associated with work ability and may increase the risk of sickness absence." When symptoms of menopause include hot flashes, sleep disturbances, mood swings, depression and anxiety, it is easy to consider how this could affect a woman's ability to perform her tasks with maximal success or to feel rested enough to attend work. 

 

I found it very interesting to read a study about "menopausal interventions" at a newspaper company in Japan. This company has 907 employees, and 98 of them are women. The employee's health is managed by 2 occupational health nurses (full-time) and an industrial medicine physician (part-time.) A gynecologist was consulted to assist in improving the workplace for women who reported menopausal symptoms. Not only were women included in some of the cases described in this study, but a male employee with concerns about his wife's health was brought to the attention of the nurse and physician. While I cannot comment with any authority about healthcare in Japan, I appreciate the fact that menopause was identified as an issue, and then the workplace was educated about the effects of menopausal symptoms (not simply in terms of work output reduction but also in terms of mental stress and depression) and then interventions were applied with success reported. 

 

What many healthcare advocates in the US have been hopeful towards is the development of a more proactive approach, and with healthcare dollars shrinking, shifting towards workplaces that assist in health management of employees may prove to be a part of that process. While the healthcare system is not a can of worms I aim to open, I would like to point out that many women suffering from menopausal symptoms are not getting the support needed to manage adverse symptoms. One of my favorite questions for a patient (this comes from Holly Herman, founding member of the Pelvic Rehab Institute) is, "Who is managing your hormones with you?" I recall the 56 year-old patient (who had a hysterectomy at 27!) saying, "well, I tried Premarin once after the surgery, and it didn't really help, so I stopped taking it." That was the extent of her assistance with hormonal management. Although hormone therapy is certainly not in the scope of practice of many therapist-rehab providers, asking such a question most certainly is. The patient can be encouraged to discuss any symptoms with her primary care or gynecologist, naturopath, or other provider who can discuss options for treatment. 


Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
Jan 09, 2015 - Jan 11, 2015
Location: Samuel Merritt University

Care of the Postpartum Patient - Santa Barbara, CA
Jan 10, 2015 - Jan 11, 2015
Location: Human Performance Center

Visceral Mobilization of the Urologic System - Fairlawn, NJ
Jan 16, 2015 - Jan 18, 2015
Location: Bella Physical Therapy

Sexual Medicine for Men and Women - Houston, TX
Jan 23, 2015 - Jan 25, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Maywood, IL (SOLD OUT!)
Jan 23, 2015 - Jan 25, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Seattle, WA
Jan 24, 2015 - Jan 25, 2015
Location: Pacific Medical Center

Menopause: A Rehabilitation Approach - Orlando, FL
Feb 21, 2015 - Feb 22, 2015
Location: Florida Hospital Sports Medicine and Rehabilitation

Breast Oncology - Phoenix, AZ
Feb 21, 2015 - Feb 22, 2015
Location: Spooner Physical Therapy

Pelvic Floor Level 2B - Houston, TX
Feb 27, 2015 - Mar 01, 2015
Location: Texas Children’s Hospital

Special Topics in Women's Health - San Diego, CA
Feb 28, 2015 - Mar 01, 2015
Location: Comprehensive Therapy Services

Pelvic Floor Level 1 - Bayshore, NY
Mar 01, 2015 - Mar 03, 2015
Location: Touro College: Bayshore

Care of the Pregnant Patient - Seattle, WA
Mar 07, 2015 - Mar 08, 2015
Location: Pacific Medical Center

Pilates for the Pelvic Floor - Denver, CO
Mar 07, 2015 - Mar 08, 2015
Location: Cherry Creek Wellness Center

Pelvic Floor Level 3 - Fairfield, CA
Mar 13, 2015 - Mar 15, 2015
Location: NorthBay HealthCare

Male Pelvic Floor - Nashville, TN
Mar 14, 2015 - Mar 15, 2015
Location: Vanderbilt University Medical Center