Women are not talking about this because it does
feel embarrassing, shameful. A leak is a leak,
regardless of how big or small that is. In fact,
it's common and not normal. C -sections are only
protected until the age of 50. One of those things
that women joke about, and that is being unable
to sneeze in public just in case you piss your
pants. 95 % of women that present with persistent
back or pelvic pain. have underlying pelvic floor
changes. Fucking hell. Are you saying that's
the number one non -pregnancy related cause of
women's pelvic floor disorders? It's Australian
constipation. The number of women who don't know
how to poo well, it's diabolical. Today's episode
is one every woman in her 40s secretly needs
to hear because we're talking about something
most of us experience, hardly any of us understand,
and almost none of us ever bring up, pelvic health.
You know that moment when you laugh a little
bit too hard? Cough at the wrong time or feel
a sneeze coming on and suddenly you're clenching,
crossing your legs, hoping for the best? For
so many women, that becomes the new normal in
midlife. But is it actually normal or just something
we've learned to put up with? Today's guest is
here to break up the silence, clear the confusion
and help us make sense of what's really going
on with our bodies as we move through perimenopause
and beyond. And before we get stuck in, if this
episode makes you think, oh, wow, that's me,
do us a favor. Hit follow, send it to a friend
because no woman should be crossing her legs
alone. Hi Preet, welcome to the 40s Formula.
Hi, thank you for having me. We're so excited
to be here. Oh yeah, we're so excited to have
you. Took you long enough, but anyway. Right,
so Preet, today we really want to talk about
one of those things that women joke about and
that is being unable to sneeze in public just
in case you piss your pants. Now, is that a new
normal? Is that something that we need to live
with? Look, the short answer is no, it's not
something that you need to live with. But I feel
like... And historically, we're not having these
frank conversations like we do about skincare.
We're discussing serums. We're discussing Botox.
But like, why not pelvic health? It's one of
the reasons why women pull back from life. You
know, have you got that friend that may be saying,
you know what, I'm not going to go out because
I need to go to the toilet every 10 minutes.
for instance, or perhaps you have a significant
loved one like a parent or a grandparent that
needs to be put into elder care because they
can't manage their continence piece. And that
is a number one reason behind why older parents
are put into assisted living in their older age.
So why aren't we having the conversation around
pelvic health sooner? And why isn't it more commonplace?
It's interesting, isn't it? Because I remember
having a conversation with a friend who was worried
about a kid's birthday party being at bounce
because it's like jumping on a trampoline. Absolutely.
Absolutely. I have a client, bless, she's incontinent
in both areas, as it were. And she was at a swim
lesson with her little one. And she had to pretend
that her little one had an accident. But it was
hers. And it was so embarrassing, deeply embarrassing
for her. And women are not talking about this
because it does feel embarrassing, shameful.
Why can't I fix this problem myself? Why? Exactly.
Look, I think generationally, mothers aren't
having conversations with their daughters. Daughters
aren't having conversations with their friends.
And it creates this taboo and shame. It actually
perpetuates this shame around pelvic health.
But what we need to realize is that You don't
have to do it alone. Help and care is available.
And just because it's been normalised through
the generations or perhaps it's even normalised
through healthcare providers that haven't had
adequate knowledge, training and skills to manage
that, it doesn't have to be the way forward.
Look, I'm not here to say that everyone who leaks
is going to be dry. There's people that are really
worse off and there's women that are manageable,
right? Like a scale. That's the word I'm looking
for. There's a scale of symptoms, right? Women
who have mild symptoms, may achieve dryness through
conservative management, right? Versus women
who have significant impacts in their urethral
function, they may need more invasive management.
That may look like surgery for some, or it might
be something as easy as a pessary, which is still
considered conservative management at the end
of the day. So I think a lot of people come into
perhaps this misconception that a... Kegels are
going to fix it all, which we know it's not the
case. We have to treat the whole body at the
end of the day. But also there is a continuum
of care that can be provided to women to help
them address their concerns. And you brought
up Kegels, which made me think of the exercise
side of incontinence, right? And the normalization
of, oh. It's squats, it's deadlifts, so I'm wearing
black pants. Yeah. Because I'm going to pee myself
is the subtext there. And it's like that to me
is astounding. There's memes around it. There's
cultures around it. It's a black pants day, you
know, and I'm like this is absurd, isn't it?
Yeah, like in the CrossFit industry, if you don't
leak when you're doing a double under, are you
really a CrossFitter, right? And I think there's
this YouTube clip of an obstetrician glorifying
women leaking on double unders. Fucking hell.
And it was a cultural thing, right? just you
know there is a point where your body is going
to fail you let's be honest okay um but that
doesn't mean you normalize yeah everyone's incontinence
experience no matter how big or small it is at
the end of the day and just because you leak
a little doesn't mean it's not a leak a leak
is a leak regardless of how big or small that
is at the end of the day and that's your body
telling you that hey perhaps something's not
quite right and to listen And go seek help. But
I also feel like a lot of women don't quite know
where to go for help either. And we want to encourage
women to reach out to their pelvic health or
women's health physiotherapist for that further
guidance and care because we can really act as
a caseworker for you and refer you to the right
people at the end of the day because it does
take a village, as corny as it sounds. We talk
about villages when women give birth, right?
But women in perimenopause and menopause need
a village as well. One clinician. is not going
to have all the answers for you at the end of
the day. You're absolutely right. And I think,
you know, normalizing, like you said, is one
part of it. But connecting with resources. This
is a dumb question, potentially. We'll find out.
Is there a centralized, like, so say I'm someone
experiencing incontinence. Is there something
I could search for? Is there a bank of practitioners?
Is there a organization of people like yourself
that I would turn to? Yeah, great question. Unified
in Singapore? No. And that's the harsh reality.
We're working on it. We've got a special interest
group, particularly when it comes to the pelvic
health physios. We're coming together to create
a bit more of a consolidated approach to care
in terms of having a bank of clinicians that
are recognised and certified that can provide
care. But as it stands, unfortunately for Singapore,
no. We do see this in other countries. I think
it's just a matter of time having the right...
women championing for that uh to be put forward
in the future can we just get back a little bit
yeah and we've obviously mentioned pelvic health
what i want to understand is what does pelvic
health actually cover like is it just like the
vaginal area is it you know the whole thing yeah
is there is it what does it not cover oh okay
look at the end of the day we're familiar with
the term core yeah okay Now, a lot of women who
we see at the clinic think the core is just your
abs. But the reality, the core is a system, right,
made up of your diaphragm, your pelvic floor,
your deep abs, and to a lesser extent, the back
stabilizers. So what we're looking at is that
the pelvic floor and pelvic health is a part
of a bigger system, okay? And hence, when we're
helping women overcome their pelvic health challenges,
we're not just looking at pelvic floor, we're
looking above. We're looking in front, we're
looking behind, but also we're looking beyond
the pelvis as well. We're looking at, is there
something happening at your feet? Maybe you sprained
your ankle, you broke your foot like 10 years
ago, and that might be playing into why your
pelvic floor is gripping and holding tension.
Or, hey, are you someone that has persistent
neck and jaw pain because you're gripping all
the time through your jaw for whatever reason
that may be? And that might also be impacting
your pelvic health. Fucking hell. That is so
interesting. Like literally head to toe. Absolutely,
head to toe, right? And that's what I mean by
what does it not cover, right? A skilled clinician
has to be able to look beyond the pelvis for
answers at the end of the day. And to that point
about Kegels being the solution, it is a starting
point. It is not your end point. And I guarantee
you, you'll be doing more than just Kegels, whether
you're trying to address prolapse, whether you're
trying to address incontinence, whether you're
trying to address menstrual pain, because you
might have a diagnosis of endometriosis or adenomyosis.
You might be someone that's got persistent lower
back pain. We've got some great research that
says 95 % of women that present with persistent
back or pelvic pain. have underlying pelvic floor
changes 95 of women okay and people you know
if you've got back pain and you're going to a
physio osteochiro unless they're trained in pelvic
health they're not actually asking the questions
like so just by the way i just want to double
check do you happen to have any pelvic floor
issues while you're at it? It's such a simple
question. It's such a simple question, but people
don't have the tools, don't have the confidence
or the knowledge to actually ask those questions
because that could be such an easy starting point
for some women who have been obviously dealing
with persistent pain but might also have an underlying
pelvic health challenge that has gone. unrecognized.
And 70 % of women don't volunteer their pelvic
health concerns unless asked. And so if health
practitioners are not asking those questions,
we're creating a society of women that have no
idea that what they might be experiencing, in
fact, is common and not normal and help is available.
And that builds that shame as well. Absolutely.
Because it's like, if I'm not being asked about
it by my practitioner, then maybe I should hide
it, right? Exactly. Maybe it's not a thing, right?
It wouldn't be relevant. If it was relevant,
they'd ask me. Exactly. Wow. Exactly. So I was
actually going to ask, oh, is it? Does this only
happen after having a baby? Doesn't sound like
it. No, it does not. I mean, when we look at
the research, let's just take, for instance,
stress urinary incontinence. So that leak that
happens with your cough or your sneeze or when
you're at bounce or when you're in the gym. The
lifespan incidence of urinary incontinence is
33%. They've got research in elite female athletes
who have never been pregnant. OK, they're leaking
at the same rate as women who have given birth
or are menopausal. OK, so what we're seeing is
that pelvic health challenges actually do start
quite early. And in particular, with this study
that I'm referring to, these girls were typically
volleyballers. netballers trampolines okay ballerinas
gymnasts so all these impact related sports um
that are bringing on these symptoms but again
no one's educating these poor young girls right
on that you know this leaking is not normal okay
you don't have to put up with it but i think
we need more funding in those spaces we need
more skilled clinicians to really push that agenda
in educating women um on what's common what's
and how these concerns can be managed. So then
that then brings me to someone who turns around
and says, oh, I had a C -section. I don't have
to worry about my pelvic floor. I've heard that
so many times. So many times. Heard that so many
times. Yeah, look, and this leads to the conversation
about what are the pelvic floor risk factors.
So when we have clients in the clinic and we're
trying to build a picture around the why behind
their symptoms, we're screening for risk factors.
So when we look at... obstetric versus non -obstetric
risk factors okay obstetric risk factors being
pregnant so regardless of mode of delivery being
pregnant and being pregnant more than once is
a risk factor i mean i hear you okay c -sections
are only protective till the age of 50. oh that's
interesting can you clarify what you mean by
that because hormones level us all out Well,
I think I was going to say seven years. Or rather
lack of hormones. Seven good years. Nope. Yeah,
hormones level us all out. Yeah, so you may not
have symptoms until peri or menopause because
the hormonal fluctuations that drive those pelvic
floor challenges. So we've got pregnancy as an
independent risk factor. Then we look at vaginal
delivery, the way you birth. So for women that
birth vaginally, if your baby weighed more than
four kilos. if there's been a prolonged labor,
so more than 90 minutes of pushing, but also
too quick, less than 15 minutes of pushing. So
we always hear about long labors being a problem.
I'm here to tell you, girlfriend, short labors
are a problem too because that's a quick stretch
on your connective tissue. Okay, so I fell in
the range, I feel. I think it was an hour with
my first and like 45 with my second. So I feel
like what you just told me is a revelation. Can
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So don't forget to support the show by using
code TFF. And then we have instrumental deliveries,
forceps and vacuums. That increases your risk
of an oasis injury or a levator ani defect, for
instance. What's that, sorry? Levator ani defect
is something that's not so commonly talked about.
It's actually where the attachment of the pelvic
floor and the pubic bone becomes impacted. So
there can be a partial tear at the attachment
or it can be a complete tear. It could be unilateral.
It could be bilateral. Is that what leads to
a prolapse? One of the reasons is a higher risk
of a prolapse. It's not the only risk. reason
why you would get prolapse. Does episiotomy affect
any sort of pelvic floor function? It can. Look,
so episiotomies are commonly related to or correlated
with ongoing perineal pain. Okay. But also the
reason why episiotomies came about was to actually
protect women from having those third or fourth
degree tears. Okay. That is what my doc said
when she did mine. Yeah. She's like, I'm here
to help you. And I was like, all right, girl,
I trust you. The problem with episiotomies, I'm
afraid to say, is that some people have just
dished them out routinely. Okay. So without,
you know, without the actual risk being there,
they'll just do it for just in case. Correct.
Oh, my God. Yeah. I have heard that before. Like,
it was like, you know, you'd only been in labor
for a few hours, and she's like, okay, let's
get this on the road. Yeah. You know, whereas,
yeah. When mine, I remember she came up to my
bedside and held my hand. Yeah. And she was like,
we need a little bit of help at this point. Because
it was, this was my first vaginal delivery. And
it had been. A while. A while. Okay. And I think
exactly what you're saying is, I think the two,
she was worried about edging into the too long
situation. After hours and hours, and she was
like. we might have. And I was like, because
the one thing in my birth plan, literally like
a one sentence birth plan. Yeah. And it was like,
please, no. Anyway, we all survived. Going on,
obstetric risk factors. Yeah, so they're the
four key ones around vaginal delivery. So pushing
for too long, not pushing long enough, baby weighing
more than four kilos and the use of instruments.
Okay, so these are obstetric risk factors and
we look at the non -obstetric risk factors. Okay,
so again, regardless of whether you've had a
baby or not. Genetics, if your mum or grandma
suffer from incontinence or prolapse, you're
highly likely. Really? Yeah. Are you hypermobile?
Have you been diagnosed with a connective tissue
disorder such as like an Ehlers -Danlos syndrome?
What that tells us is that your connective tissue
is just too stretchy and not supportive enough.
That puts you at higher risk of things like prolapse,
okay, for instance. And those girls are often
the ones that are doing your gymnastics and your
ballet. I was thinking Cirque du Soleil, but
also gymnastics. I mean, it's kind of the same.
You follow the same. It's a continuum. That's
the word I was looking for earlier, continuum.
Oh, my God. Anyway, I digress. Then we move on
to things like, fuck me, brain fart. Let me just.
rewind a bit so we've got things like genetics
we've got things like uh connective tissue disorders
we've got things like hormones that's the word
i was looking for so you know whether you're
postpartum and you've got a decline in estrogen
whether you're in peri and you've got your progesterone
declining and then you've got your estrogen tapering
off and then menopause you've got your estrogen
you know our vulva vaginal tissues are very much
estrogen dependent they need estrogen at the
end and it's not typically the oral type it's
more the vaginal estrogen just for clarification
there and we can elaborate on that a bit later
And then we move on to things like BMI. BMI greater
than 25. Greater than 25? So just in the overweight
category. That is lower than I expected you to
say. To be honest, we could harp on about how
crap BMI is as a measure because it doesn't accurately
tell us body composition and all the rest of
that, but I'm just going to leave it at 25 because
that's what the research tells us. Things like,
are you in an occupation where you're constantly
lifting Herbie? Yes. Yes, I am, doctor. Can you
tell me more? But I'm sure your form and pressure
maintenance is good. I mean, they're pretty good.
And things like, you know, do you suffer from
a respiratory illness, like an asthma that's
poorly managed? So you're constantly coughing,
coughing, coughing. Pressure, pressure, pressure.
So it's literally the repetitive pressure. I
would never have connected that. Wow. And the
big one is constipation and straining. The number
of women who don't know how to poo well, it's
diabolical. And the problem with like if you're
not pooing well and you're not completely evacuating
and you're pushing every time you're pooing,
you're just weakening the connective tissue,
right? And beyond that, estrogen gets created
through our faeces. And so if you're not going
to the toilet and regularly evacuating, that
estrogen gets reabsorbed by your body, right?
And so that might be impacting your periods.
Are you saying that's the number one non -pregnancy
related cause of women's pelvic floor disorders?
Constipation. Australian constipation. I have
never, ever heard that. And I've been also in
this field for a while. That is stunning. Yeah,
absolutely. So yeah, regardless of whether you
had babies or not, if you don't know how to poo
and you don't know how to poo well, you might
have issues wow yeah that is scary yeah that's
my bread and butter in the clinic like screening
for bowel health talking about poo that's my
bread and butter no but i think and that relates
back to us you know in the nutrition field as
well because constipation is a super commonly
reported symptom so you guys are looking at from
it From a nutrition perspective. I'm looking
at it from a biomechanical perspective. Like
how do you poo? Do you actually relax your pelvic
floor muscles? Are you straining and pushing
every time you're doing a poo? Let me teach you
how to poo without pushing and straining. Let
me put you in a bowel routine. I need to know
how you'll be teaching people to poo. Do you
give them a handout? I do have a handout. I can
share it with you later. I can also go through
it right now and teach you how to poo. I think
that would be quite handy for our audience. So
look, the easiest, look. Let me put it like this.
The toilet is the most horrible invention for
our pelvic floors ever. Because of the weird,
okay. Yeah, because you're not in the correct
position. Correct. So when we're pooping, right,
we want to think about being relaxed. Defecation
requires the pelvic floor to relax and let go,
okay? If you're straining, so for instance, I'll
pretend you're my client. Pretend that seat that
you're sitting on is your toilet. How would you
position yourself to poop? I kind of go, I'm
kind of leaning forward a little bit. Yeah, I
think that's like a general half lean. Half lean,
yeah. Do you use a squatty potty or a stool?
I don't, not sure. My toilet is actually quite
low because I've got little legs. Yes. In England,
I do have to use, I laugh and I joke, my family
laugh at me, but I have to use the stool because
otherwise I can't, my feet won't rest on the
ground. I come like a little kid swinging. And
talking about kids swinging, make sure your kids
don't swing when they poop and pee. Feet firmly
planted. So if they're swinging mid -air, no.
Wow. Are you saying because that will instill
the incorrect pooping posture? Yeah. Absolutely.
So, yeah, that's how you poop, right? So what
I'd be looking at is looking at the relationship
of your knees to your hips. Are your knees higher?
Or lower. And they should be higher, right? Higher.
Okay. Because if you think of a squat, right?
Yeah. Knees are very much higher. That doesn't
have to be all the way up into your chest. What
you're saying is I should not have renovated
my bathroom in my 1977 Singapore house from a
squat toilet. Because when we moved in, it was
two squat toilets and one bowl. And now it's
three bowls. So I've done a disservice to my
family. The previous owners must have had amazing
health. Amazing health. That's true. Absolutely.
I'm going to have to get in touch. So, yeah,
we're looking at the relationship of the knees
to the hips. We're looking for whether you're
leaning forward, body weight supporter. Then
I'm looking at what you're doing with your bum
and your belly. Are you sucking it in and pushing?
Are you Valsalva -ing? We don't want to Valsalva
when we poo. And again, for a few reasons, because
we also don't want to poo when we're Valsalva
-ing. There's that worse in both directions.
Absolutely. Things like, you know, what are your
shoulders doing? Are you breathing out? Are you
sucking your belly in? Fundamentally, these are
the things that we'd be looking for when pooping.
But if you wanted to make a simple change to
the way you poo to minimize your risk of straining,
get a squatty potty. And then go see a physio
and understand whether you're pooping well or
not. Okay, business idea for you because your
voice is so calming and lovely. can you record
a poo track? Like a 20 second poo track. Kind
of like 90 breath work, right? Can you report
a poo track, a calming background? I'm going
to just give a shout out to a wonderful physiotherapist
by the name of - Who's done this? Who's done
this? Yeah, Shelly Prosko. It's the toilet meditation.
It's called the airbags analogy. You can YouTube
it. I give it to everyone that comes to my clinic.
You meditate your poop out. I love it. We are
putting that in the show notes. Absolutely. We
are putting toilet meditations. That is fantastic.
Ask me to remember what the acronym stands for
because I don't remember off the top of my head.
But, yeah, it's all about, like, meditating your
poop. Because we are – we're busy. We don't have
time to shit. Simple matter of fact, you know.
You know, you're a teacher and I think – I'm
so sorry, teachers. I really feel for you. You're
rushing between classes, right? You might be
an office worker rushing between meetings. You're
not prioritising your pelvic health, you know.
You're holding on as long as you can hold on,
right? at the end of the day, trying to get through
all your competing priorities. But please, just
when you need to poop, poop. Don't miss the boat,
okay, at the end of the day. Is holding your
pee bad for your pelvic floor? Great question.
Look, there's a saying in pelvic health, you
know, the bladder makes for a great sailor, not
a great captain, okay? So it can be trained,
okay? We have a lot of women going just in case,
you know. I don't know if there's going to be
a toilet there. I may as well go now. Okay. And
we see that in like our kids when we're like,
okay, we're about to leave the house. Can you
please go do a wee because I don't have to stop.
Yeah. I do it. Oh, no. I do it. Guilty. I do
it as well. I do it too. Yeah, don't worry. Yeah.
No shame in admitting that, okay. But what we're
doing is we're setting these kids up for future
toilet habits that we're not going to serve them
well, right? You know. Do a wee when the urge
is moderate or strong, okay? You don't want to
go in there and just a little trickle. The problem
with my kids is they tell me they need a wee
when the urge is too far gone. That sounds about
right. Yeah, kids, they're frustrating. And you've
got three of them as well, right? Actually, we
all have three kids here, don't we? A lot of
kids. A lot of experience in this room. And so,
yeah, look. People are not just only pushing
or straining to do a poo, but we're also power
peeing as well, right? And straining in general
is a pelvic floor no -no. okay so we want to
be able to poop well and pooping is not just
about what you're putting in your body it's how
it comes out of your body so we refer to as defecation
dynamics and that's what we would coach and guide
our patients through in the clinic on how to
optimize that where we feel like there's a large
dietary component that needs to be managed we
would refer them out like go speak to someone
that can help you with your guts and what you're
eating and making sure you're getting adequate
fiber right the number of us that aren't eating
enough fiber is ridiculous as well right at the
end of the day and so So to my point earlier
about it takes a village, right? It's not just
one clinician. I'd love to be able to just see
one person that can solve all my problems, but
the reality is we all have our strengths, we
all have our weaknesses, we all have our training
and skills, and we need to stick within that.
And you are going to need to see more than one
person to navigate these pelvic health challenges,
guaranteed. And I think this leads really nicely
into our Fuel Your 40s by The Meat Club. And
they actually have a specific question for you.
And the question they have for you is, we talk
a lot about fueling our bodies. And from your
perspective, how does food impact your pelvic
health? Look, whether it's a muscle you can see
or not see, it's muscle at the end of the day.
So those biceps and triceps and quads and hamstrings
you're trying to build through, strength training
and eating adequate protein that all needs to
go to your pelvic floor too at the end of the
day because it is a muscle it's not just muscle
it's connective tissue as well it's ligaments
okay it's nerves it's blood supply as well so
regardless of whether it's a muscle you see or
don't see you need your protein you need your
collagen you need to be hydrated it applies across
the whole body We completely agree. And that's
why we love the Meat Club as our sponsors, because
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And I think that's the thing. A lot of people
think about what they're eating and muscle. And
I think all they're thinking of is biceps. booty
yeah exactly but you know it's not just about
that it's about making sure that the whole body
is fueled yes yeah exactly i feel like obviously
we've spoken a lot about shitting obviously a
lot about pissing yeah now what about hormones
obviously you've touched upon it yeah and you
said that if the childbirth and childbearing
doesn't get you your hormones will Please tell
us what can us women in our 40s expect during
this time and what can we do about it? When you're
in your 40s, right, what starts to decline is
your ratio of progesterone and estrogen, right?
That's what we're commonly seeing. And so it
starts with your progesterone declining, okay?
The way I like to explain it to people is your
progesterone is a lawnmower. And your estrogen
is the grass. Okay. I like that. Okay. And so
the lawnmower keeps the grass in check. Okay.
So as your progesterone starts to decline, you
get more estrogen in comparison, right? In that
ratio. And so what you might start to notice
is changes to your menses cycle. Okay. Heavier
periods. For instance, irregular periods. You're
more PMS -y. Do you feel like you want to kill
your husband? Oh, yeah. I mean, yes, but that's
28 days per month. You're starting to get a lot
of those emotional side effects as well, right?
And then we look at things like what's happening
with the rest of the body. You might get generalized
joint aches and pains. You're starting to see
that loss in your lean muscle mass. If you've
been getting follow -up for bone mineral density,
you might start seeing a loss in your bone mineral
density. What about things like, you know, that
sudden frozen shoulder that you got and you're
in your 40s? Okay. Or that plantar fasciopathy
when you wake up in the morning and you feel
like you're walking on glass. Okay. Or more of
that lateral hip glute pain. You know, these
are really common hallmarks of this transition.
Typically when people experience those symptoms,
they're going to be going to a physio, osteo,
chiro, get in management. But actually there's
probably a hormonal component driving that as
well. And so if you've gone and got physio, osteo
or chiro and it's not getting better, that's
a sign for you to perhaps go to the GP and understand
what your hormones are doing. Absolutely. And
I think you're absolutely right that it's confounded
with I have a physical problem, I need to see
a physio, osteo. Also, it's aging. Yes. This
is aging. And it is meaning you don't, you don't
reach this level of kind of hormonal reshuffling
until you age. Absolutely. For many of us. But
the point is like, yeah, it's aging, but it's
specific to something that we can intervene.
And I think that when people say it's aging,
it's just like when people say it's genetics,
it's like, it's this untouchable force that no
one could ever, you know, but it's like, but
a lot of times it's menopause or hormones and
it's epigenetics. So it's two things that you
can control. Yeah, absolutely. I think perhaps
that served people well historically. We didn't
have the knowledge. We didn't have the resources.
But that doesn't serve us well anymore. We're
more proactive when it comes to healthcare, right?
And we have more means to address and access
these things. And why not? Yeah. So then we're
looking at things like what's happening to your
bladder as a result of these hormonal fluctuations,
right? The bladder becomes less elastic. It feels
like my bladder has shrunk. Why do I have to
keep going to the toilet even though I just went?
You might be experiencing urgency, like suddenly
have to go to the toilet that you can't defer.
Is that because of the lack of... Yes, so the
bladder compliance can reduce. So your bladder
capacity reduces, but also reduce, I'm sorry,
the lining of the bladder is estrogen sensitive.
Okay, so when there's less estrogen, it makes
it more sensitive. So those nerve endings are
more exposed and they're always triggering. So
that's the, you know, the 3am wake up when you
need to, when you should be sleeping, you're
waking up to go for a wee. Yeah, potentially,
look. Wake up once at night is considered still
quite normal. If you're having to go more than
two times a night, we would refer to that as
nocturia and we would want to understand why
are you waking up so often? Is it something related
to like your diabetes or is it that you're, it's
a habit, like you just have a habit of making
up for the lack of water you've had through the
day and you're chugging it down after 9pm at
night. It could also then, I guess, be like a
sleep apnea type thing. Absolutely. Yep. Okay.
It could be a variety of different things at
the end of the day. For instance, you might feel
like you're getting UTIs all the time because
the lack of estrogen is creating this unhealthy
environment for bacteria to thrive. Wow. Okay.
Or if you're in a habit of going to the toilet
quite often. frequency you might find that you're
not completely emptying your bladder and that
might be leaving a little bit of wee in the bladder
and that might be irritating the lighting as
well that might be giving you a UTI and you would
want that confirmed on a urine culture or genuinely
it just might be That you've got reduced bladder
compliance and you also might have pelvic floor
dysfunction where your muscles are stiff and
tight that give you this impression of a UTI
-like symptom. But it just might be your pelvic
floor not relaxing enough. To like empty out
the wee. Yeah, absolutely. And you might be getting
these phantom UTIs, which is just more of the
pelvic floor being switched on tight and off.
Because like every other muscle, it needs estrogen.
And when it doesn't have estrogen, it undergoes
atrophy. becomes so stiff is vaginal estrogen
the answer yeah it is so if someone presents
menopausally um with a pelvic floor complaint
the american menopause guidelines actually recommend
vaginal estrogen as a first line of manager for
these women it's good to know yeah yep so not
oral okay does oral do anything like no it needs
to be locally does you know the wow so it literally
has to be vaginal to address the symptoms you
are referring to specifically see i don't think
that is very clear yeah no because i think you
just think oh i'll just take the cream or whatever
it is and it will stop my symptoms but if it's
not stopping the symptoms then clearly it might
not be the right type of estrogen wow yeah that
is good to know now sort of switching up a little
bit one of the other things i think women always
sort of talk about is aesthetics and the way
they look and we tend to get women who Might
be slim all over, but then they've got this protruding
belly. Yep. And they want to say, I just want
to lose weight here. Is that weight or is that
something else? You guys are the experts in this
space. Come on. I mean, I kind of, I kind of.
Look, you know, it's hormonal. It's connective
tissue quality. It's. Postural. Subcutaneous
fat. It's postural. It's a lack of muscle, right?
How many of us are in occupations where we're
sitting all day every day? There you go. You
know, we're hunched over, okay? What's happening
to your diaphragm? It's getting compressed, right?
And what's happening to your muscle length and
tension relationships? They're getting a bit
stiffer and tighter as well, right? You know,
back to the point about the core, you have to
address the whole system, right? You know, it's
not going to be as easy as, yeah, I'm just going
to do a shit ton of crunches and be gone belly.
We've got to look at the whole system. We've
got to look at your lifestyle. What's your stress
like? What's your sleep like? What's your nutrition
and hydration status? So unfortunately, yes,
it's a common hallmark for women as they transition
through many perimenopause and menopause, but
it's not just hormonally mediated. We've got
to look at the whole picture at the end of the
day. Yeah, all those, I mean, and again, it's
a marketing tool, right? Oh, do you suffer from
hormone belly? You know, and it's like - Menobelly.
Menobelly, yeah, all these things. And it's like,
yeah, but like - you suffer from not sleeping
and exactly zero water and not exercise there's
so many things and like what's your alcohol intake
like yeah there you go what's your intake like
yeah well and you know this is back to the aging
thing right where it's like blaming everything
on aging but but here's where aging does step
in where it's like yeah why didn't i have this
in my 20s well the accumulation of bad or forgotten
habits over 20 years is going to hit you when
you're 40. It's not going to hit you when you're
20. So that's where the aging thing is very real.
Very real. The big wheel keeps on turning. Proud
Mary keeps on burning and it ends up in your
stomach. Unfortunately. Some things you can't
outrun. You cannot. You've got to call a spade
a spade at the end of the day. I feel like when
I – I know this is not 40s necessarily, or it
could be because we do see women having – children
later and i think that often confuses diagnosis
as well like is this postpartum or is this depression
or is this peri because we are having families
later which can delay diagnosis so mandy you
know how i've been on this journey about improving
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and use that code TFF today. Moving on. We're
going to do a little segment called Hot or Hype.
And this is fast paced. Just whatever comes.
You know, you tell me whether you think it's
hot or hype. I'm going to ask you a few questions.
Some of them you've already answered, but we'll
just get your quick take on it. Everyone should
be doing Kegels every day. Hype. Is there a place
for Kegels though? Like, is it one of the things?
Yes. Okay. Okay. Leaking a little bit when you
laugh. I hope you're not leaking that. This is
my confident leaking laugh. I'm hype. Strong
glutes equals a strong pelvic floor. Hot. Ooh,
can you expand? Glutes save everyone, correct?
Absolutely. Okay. Absolutely. Glute strength,
hip strength. I'm just putting them together.
Look, they've done research and I'm going to
specifically focus on outcomes for stress urinary
incontinence. So women who leak with a cough,
sneeze, run, jump kind of stuff. They looked
at, Two groups of women, women who leaked and
women who didn't leak. And they did studies on
pelvic floor strength, tone, and then they also
analyzed glute and hip strength. What was the
difference between the two groups? Can you guess?
Bigger booties. Stronger hip and glutes. Does
not surprise me. Because when you were saying
about what muscles make up the core, I include
glutes. I include glutes because I do feel like
glutes are the backside, keeping the front side
where it needs to be. I refer to it like an onion.
There's layers of muscle and layers of support.
And to my earlier point, your pelvic health challenge
isn't just about what's happening in the pelvis.
We've got to look head to toe and what's driving
that at the end of the day. Pelvic health physio
is only for new mums. Right. You can't lift weights
after 40 safely. Are you sure about that? I am
only kidding. And perimenopause makes pelvic
issues inevitable. Look. inevitable look it's
going to happen but there's so many modifiable
risk factors we can work on yes that can help
improve your outcomes so basically it's not just
one little section it's going to be your whole
body your whole life so women sort it out yeah
yeah look sooner rather than later yeah so you
can just get on with life yeah okay and On that
point, like it's never too late. So for those
that feel like, oh, they've missed the boat because
they didn't come in after they gave birth. If
now you have the bandwidth and the time and the
resources, that's like 15, 20, 30 years down
the track, it's still okay. There's still something
you can do about it. Because it's a muscle at
the end of the day and you can always train muscles.
But also to the point, it's not just a muscular
problem when it comes to pelvic health challenges.
It could be. a connective tissue problem. It
could be a neuro problem. It could be a glute
problem. It could be a diaphragm problem. It
could be a foot problem. So it's not just about
muscles at the end of the day when it comes to
optimizing pelvic health outcomes. Can I ask
a quick question? Yeah. Because I think this
is something when I refer my own clients to pelvic
floor physios, sometimes, and now this also makes
me think, do they really go? Sometimes they come
back and say, yeah, she did a quick assessment
and it was all good. And I said, did she see
you internally? And they're like, no, no, it
was just like an external palpitation. And I
was like, I don't think that's a pelvic floor
exam. Can you just walk us through what a pelvic
floor exam or assessment might look like? Yeah,
sure. So look, the gold standard of pelvic floor
integrity assessment is a internal vaginal examination.
So finger up the vagina. There you go. Okay.
I had a wand. Is that, am I a fancy? Was that
like a ultrasound wand? Yes. Okay. Yeah, different.
I think they're probably looking at something
else there, like your ovaries and your uterus
and stuff like that. But anyway, so pelvic floor
examination, gold standard, vaginal examination,
fingers into the vagina. What are we looking
at? We're looking at muscle tone. We're looking
at muscle strength. And you can feel that. You
know what a good muscle tone should feel like.
Yeah, I've done a lot of pelvic floor assessments.
We're looking at vaginal wall integrity. So how
stiff or loose the walls of your vagina are because
that might indicate presence or absence of prolapse,
for instance. So they want to be stiff or loose?
Stiff. Okay. Well, stiff might give the wrong
connotation. You want them to be firm. Firm,
tender, like a good steak. Sure, we can talk
about steak. Then we're looking at things like...
is there a presence or absence of like tender
points or bits in the muscles that might be contributing
to some referred pain or pain that you might
get during sex or pain that you get with your
menses cycle, for instance, whether it's ovulatory
or whether it's when you're on your period, for
instance. We're looking at proprioception. Can
you feel if I'm on the left of your pelvic floor
and the right of the pelvic floor? We're then
relating that to what's also happening at your
obturator internus, which is a common hip pelvic
floor muscle that connects. pelvic floor to your
hip which is very much critical for good functioning
pelvic floor um yeah throughout the lifespan
so these are some of the assessments we'd be
looking at the reality is when you're doing a
pelvic floor exam you're getting a full picture
okay a pelvic floor exam may not be appropriate
for everyone they we may not be given the consent
to do a pelvic floor exam or it might be contraindicated
Okay. So what are our options in those scenarios
and situations? We might recommend a real -time
ultrasound exam. So similar to when you go to
the gyne to look for a baby, we would be looking
at your pelvic floor and more specifically how
the pelvic floor changes the way your bladder
looks and moves on a screen. What we're not going
to be able to elicit from a 2D image is strength
tone. What we're going to be able to see is when
you do a pelvic floor contraction, is it switching
on? Is it switching off? Is it relaxing? Is it
stretching? Can you poo well? So we can train
these things using the real -time ultrasound,
but we're missing some critical information that
gives us a comprehensive understanding around
your pelvic health. And in those scenarios, we
might even get patients like, no, I don't even
want an ultrasound. So what are we left with?
Then it's external palpation. And so we might
have someone inside lying and we're palpating
along their butt crack, just trying to get a
picture or understanding. But it's relative really
then to the patient preference. Preference, what
are their concerns? Honestly speaking, vast majority
of our clients, 90%, come in with the mindset
they're coming in for a pelvic floor check at
the clinic, unless there's a contraindication
or perhaps they haven't given consent. So to
your point about checking abs to understand pelvic
floor integrity and functioning, no. That's good
to know. Okay, so then what are the sort of treatment
options out there? We hear about Kegels all the
time. Everyone always tells you when you're pregnant,
you do your Kegels. Yeah, we've now learned about
vaginal estrogen for hormonal -related symptoms.
What are some other treatments? There's loads.
Oh, my gosh. Like, just strength training stuff,
right? Head to toe. You know, we spoke about
strong glutes, strong hips. Okay? Yeah. Other
treatments from a physio perspective would be
like... What are your bladder habits like? What
are your bowel habits like? We spoke about how
to poo. For instance, we might be looking at
things like breath work, diaphragm mobility work,
thoracic mobility work, stress management strategies.
Poo meditation. Poo meditation, absolutely, absolutely.
Pelvic floor meditations to downtrain sore, tight,
painful pelvic floors. Do those exist? Are we
talking about meditation tracks that you can
listen to? So there's an app called Insight Timer.
And they've got pelvic floor meditation tracks
on there that we might recommend our clients
who might be suffering from pelvic pain, for
instance. Wow. Yeah. That's so interesting. So
basically, not a lot, but some women who suffer
from pelvic pain might just be because they're
stressed out and they're just not able to relax.
So, you know, in a situation where they're trying
to have intercourse, they can't because... It's
just all too tense. Look, that might be an oversimplification,
but yes. Okay. You know, I think culture and
intimacy and sex is a bit like, you know, we're
all in a rush, right? We just want to get it
done, put a tick in a box, right? It takes anywhere
between 17 minutes to 40 minutes for a woman
to be sufficiently aroused. Wow. Okay. You might
be aroused objectively, i .e. you might be wet,
you might be feeling it down there, but if you're
not aroused subjectively. it ain't going to happen.
Yeah. Okay. And it's not going to happen comfortably.
Absolutely. So, I mean, that might not be the
case for everyone, but I'm just like considering
the audience, you know, we have lots of highly
functioning women who are busy, busy, busy and
don't have time for things and they just need
to get it done, but maybe not be setting the
environment and the context to allow for that
to organically happen in a comfortable manner.
But also like if you're someone that's lacking
estrogen, you've got reduced lubrication. muscular
muscular atrophy sex is going to be uncomfortable
yeah in that menopausal period yeah and it may
even start in perimenopause for some as well
just depending on how much of a fluctuation there
is in their estrogen status wow so much to think
about and i just here i was thinking we're going
to be talking about you know how did you get
exactly and done yeah or this is only for an
episode for women who've had babies no this is
for everybody yeah i think Yeah, if it's one
thing I could really get women to think about
is, or just remember that just because you've
had a baby, just because you haven't had a baby,
just because you're old, just because you're
young, it doesn't mean you're going to be immune
to pelvic health challenges at the end of the
day. Because there are some risk factors that
exist that dictate the functioning of your, the
optimal functioning of your pelvic health. And
it's never too late. But it's always better to
seek help sooner rather than later just so you
just can get clarity and get a plan in place.
And like with most things around lifestyle management,
it takes time. It's not going to be like you
go in for a session and you get taught how to
do Kegels and that's going to fix that and poverty.
It takes time because, you know, humans are intricate
beasts at the end of the day and it's not clear
cut. And it does take... A team to address concerns.
Wow. I feel like you've given us so much to think
about. And, you know, everything you've told
us is so relevant to our audience. You know,
whether they, like you said, had kids, haven't
had kids. You know, the ones who are approaching
40, the ones who have passed 40. But before we
go, we do have one final question we would like
to ask you. And that is, what's your 40s formula?
What advice, mantra, or just tips would you like
to share? with women who are in their 40s that
are listening in today? You want my honest? Yes.
And this is you. This is Preet. This doesn't
have to be rep and physio. I just don't give
a fuck. Yes. I sat there thinking about it. I'm
like, you know what? This is what feels authentic
to me. I just don't care as much as I used to
anymore, right? Yeah, I value my time. I value
my energy and I value my people. You don't exist
within that realm for me. I'm sorry. It's nothing
personal. It's just it is what it is. I only
have so much capacity at the end of the day.
And by nature of the work I do as a pelvic health
clinician, like a lot of my energy gets zapped.
And so that leaves very little for everyone else,
I think, at the end of the day. So respectfully,
just. not giving a fuck that's it girl and I
think that's the big thing isn't it it's the
capacity that we have as 40 year olds and mothers
and women who are working and just whatever is
going on in the world there's just so much information
so much stuff going on and you're right if you
don't fit within what our boundaries are it's
just too much and you can be left to feel perpetually
inadequate yeah Because, yeah, we are surrounded
by information and, you know. this whole push
to age well live well you know are you getting
enough exercise are you getting enough protein
are you eating your collagen are you doing your
pelvic floor exercises are you doing xyz like
you start to realize that self -care list really
builds up it's getting longer and longer I feel
like every year and so we are at risk of actually
overwhelming ourselves as well trying to keep
up with this and so I do worry um and I think
it's can be quite challenging for women to take
away what they need and prioritize but given
zero fucks to the things that don't matter it's
definitely hard cuts yeah absolutely well thank
you so much for being here pre we've really really
enjoyed this conversation and honestly you've
given us so much to think about things i didn't
even think about yeah absolutely you you've brought
new information to the table which is always
why we're here so thank you so much thank you
for having me thank you Thank you. Because the
way the teleprompter works, sometimes there's
a gap, so we just stop. Yeah, until the next
paragraph. Yeah. You know, like as it's running.
Yeah. And sometimes our editors don't catch it.
So we have to always, they'll be like, today's
episode is about something that we all, and then,
you know, it's like, no, but you've got to tighten
that up. Yeah, it's like, we can't have that
like that.