I am delighted to connect with Dr. Rena Malik today. She is a trailblazing urologist who is revolutionizing the conversation around taboo topics. With over 400 million views and 2 million subscribers on her YouTube channel, Dr. Malik has become a leading voice in combatting medical misinformation and empowering individuals with knowledge on critical health issues.
In our discussion today, we dive into the shame and stigma many women face when addressing genitourinary concerns, offering information on the pelvic floor and pelvic floor dysfunction. We explore urinary tract infections, overactive bladder, and the causes of pelvic floor dysfunction and touch on the impact of incontinence, prolapse, and the changes women experience in perimenopause and menopause.
This conversation is an invaluable masterclass for women, and I am excited to have Dr. Malik returning in the fall for an exploration of topics related to women’s sexual health issues and arousal in perimenopause and menopause.
IN THIS EPISODE YOU WILL LEARN:
Why do so many women feel ashamed or uncomfortable discussing genitourinary issues with their healthcare providers?
Dr. Malik clarifies what the pelvic floor is
The importance of learning how to relax and align the pelvic floor
Why many women experience recurrent UTIs, and how to prevent them from occurring
Dr. Malik dives into the three categories of intervention to regulate the bladder
How one in three women experience incontinence
The benefit of doing Kegels
What causes bladder or rectal prolapses?
Why patient empowerment is essential for women
Why many disorders and dysfunctions intensify with the hormonal changes that occur in perimenopause and menopause
Bio: Dr. Rena Malik
Dr. Rena Malik is a board-certified urologist with a talent for dispelling medical misinformation, discussing intimate topics, and educating the general public. With over 300 million views and 2 million subscribers, her YouTube channel, Rena Malik, M.D., has become a go-to destination for frank, evidence-based discussions of taboo topics. Men’s Health Magazine named her as one of the top 10 health influencers in 2023. Dr. Malik is regularly featured by media outlets, including Insider, Men’s Health, Self, Scientific American, Bustle, and US News & World Report, and has been a guest on multiple podcasts, including the popular Diary of a CEO, Huberman Lab, and Mel Robbins Podcasts.
Dr. Rena Malik specializes in sexual medicine, Female Pelvic Medicine, and Reconstructive Surgery (Urogynecology) and is a Menopause Certified Menopause Practitioner. Her practice, Rena Malik, MD, offers patient-focused, individualized care in bladder health, sexual dysfunction, hormone management, and the compassionate management of non-narcotic pelvic pain. She is located in Beverly Hills and Irvine, CA, and sees patients virtually from the states of CA, FL, IL, MD, NY, NJ, TX, and VA.
Dr. Rena Malik's extraordinary contributions to the realm of urology have earned her the distinguished title of the 2023 American Urological Association Young Urologist of the Year. With a prolific portfolio boasting over 80 peer-reviewed publications, she continues to contribute to the advancement of innovation in the field of urology. She is an online content editor for the Journal of Urology and Urology Practice journals.
“We don't teach people female anatomy, so we don't know what is normal, and when something is abnormal, we don't know.”
-Dr. Rena Malik
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Submit your questions to support@cynthiathurlow.com
Connect with Dr. Rena Malik
On her Website
On all other social media platforms: (@renamalikmd)
Transcript:
Cynthia Thurlow: [00:00:01] Welcome to Everyday Wellness Podcast. I'm your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Dr. Rena Malik. She's a trailblazing urologist who's revolutionizing the way we talk about taboo topics. She has over 400 million views on her YouTube channel and 2 million subscribers. And she's become a leading voice in dispelling medical misinformation and educating the public on intimate health issues.
[00:00:49] Today, we spoke about the degree of shame and stigmatization women have about discussing genitourinary issues, specific information surrounding the pelvic floor as well as dysfunction, we spoke about urinary tract infections, overactive bladder, what contributes to pelvic floor dysfunction? The impact of incontinence and prolapse, and lastly, changes in perimenopause and menopause to the genitourinary system.
[00:01:16] This is an invaluable masterclass for women, and I look forward to having Dr. Malik back in the fall to dive deeper into other topics, including arousal versus desire and sexual health issues that women in perimenopause and menopause experience. I know you will find this to be a truly invaluable conversation.
[00:01:37] Dr. Malik, such a pleasure to connect with you. Welcome to the podcast.
Dr. Rena Malik: [00:01:42] Thanks so much for having me.
Cynthia Thurlow: [00:01:44] Why do you think that so many women are ashamed or kind of stigmatized when they think about having conversations with their healthcare practitioners about genitourinary issues? I feel like that area of the body, more so than anywhere else, women are so ashamed to talk about that they feel uncomfortable. And yet, obviously, healthcare professionals, this is kind of the language that we speak, but I would imagine for you, you probably have patients every day that come to you that are still feeling a significant degree of discomfort having these direct conversations.
Dr. Rena Malik: [00:02:16] Yeah, I mean, look, there's so many different reasons. One, it's obviously societal. Two, it's lack of education. And those are the big ones. But I would say that certainly in medical school, how much time did we get learning about vulvar genitalia, female GU anatomy? Very little. And in exam, you get to do like maybe one exam on a practice patient before you actually go in to do real exams. And, it's not sufficient. And people don't have the expertise of looking at that genitalia all the time whereas male genitalia is visibly know outside the body, people look at it all the time, they can very easily identify when something is abnormal or out of place.
[00:02:58] Whereas for females genitalia, like, I can't tell you the number of times I've taught a medical student to put in a catheter and they've actually tried to put it into the clitoris rather than the urethra because they don't know the difference. And that's not their fault. It's that we don't teach people female anatomy. So, we don't know female anatomy, what's normal. And then when something's abnormal, we don't know.
[00:03:19] And I have a really actually sad story. I remember in fellowship, I took care of a patient who ended up having a vulvar cancer. And we went in to operate on her, and I was in the operating room, and I was like, “How could they miss this?” She had even seen a gynecologist, and apparently that gynecologist had just looked at the cervix and didn't really do a full exam and had missed this cancer. And so even the people that we are-- And this is obviously not a common scenario, but I'm saying even sometimes the people that we are looking to be experts in the area just don't have the expertise to look at the entirety of the vulva. So dermatologic conditions, cysts, abnormalities, urethral abnormalities, things that come up, so I always encourage women take a mirror and look, take a mirror, spread your legs, put it between your legs and take a look. Handheld mirror, super easy to do. Know what it looks like at baseline, so that when you're like, hey, something feels different, you can always go and look again. And you should be looking. You should know what your anatomy is. You should know for that purpose and also for pleasure purposes, you should know what feels good and what doesn't, and so you can guide your partner because they don't have a problem guiding us, so we should be able to guide them as well.
[00:04:31] And then obviously there's the societal thing, like, “Oh, for many, many years, we thought that problems like that women had were due to hysteria because we had a uterus and all these things.” It stems from patriarchal beliefs in society about women and how we are whiny or maybe can't handle pain or whatever the situation is, but there's a lot of societal thoughts about women should be like and how they should handle themselves. And if they complain that it's not really an issue. And we see that in so many areas of medicine. So even in Urology, there's actually data that women with bladder cancer get diagnosed later because very often they're treated for UTI, after UTI, after UTI, and they're not investigated thoroughly for blood in the urine to identify bladder cancer. So, there's just so many areas in medicine, heart attack are diagnosed less frequently that-- Where we see there's this bias against women and it's also because of lack of education. So, those are the real reasons.
Cynthia Thurlow: [00:05:33] And it's interesting to me because I'm the byproduct of-- Many people in my family are in medicine, I remember my grandmothers were very distinct about we had to use proper terminology, whether we were talking about our ear or another body part. I remember my father saying, who was not a medical professional, like, “I don't know why you make such a big deal about it.” And my grandmother's saying it is so important for young women to be able to properly talk about their bodies and not feel a sense of shame.
[00:06:00] And one of the things that I think is helpful is to orient people to the anatomy of the body. So, when we're looking at the pelvis, there are organs in the front, kind of the anterior, there are organs in the middle, and then organization organs posteriorly in the back. And I think it's helpful because when someone's listening, they may just be thinking, “Oh, we're just talking about the vulva and the vagina, we're just talking about the urethra.” But there's so much more to the pelvic area that can be impacted by a lot of things that I'm sure we'll talk about today, but I think having some degree of orientation about where these organs lie can be very helpful and beneficial.
Dr. Rena Malik: [00:06:36] Yeah, absolutely. So, when we think about it, the pelvis incorporates 1, the pelvic floor, which I talk about a lot. It's this bowl of muscles that holds everything up. And it's really, really important for stability, for continence. So, making sure we keep our urine and stool for being able to urinate and defecate. It helps with sex. It helps with having a baby. So, lots of different functions of that pelvic floor and super integral to a lot of the issues that you'll see with pelvic floor, pelvic organs. And sometimes you'll see things like--
[00:07:09] Because the other organs are right above it, the bladder, the uterus, the vagina, the rectum, all those organs are sitting on top, so you can have issues like constipation or going to the bathroom more urgently or more frequently, or urinary leakage or pain with sex, pain with just any discomfort down there can all be related. And it's not always that, but it can be related to the pelvic floor. So, we have all these structures there that are all interrelated. And the pelvic floor is part of our core. So oftentimes if you have issues with hip dysfunction or you have abnormalities in your musculature in the abdomen or the back, that can also affect your pelvic floor or your pelvic floor can affect your back, so people will have lower back pain or people will start having a way they sit, which is maybe they're sitting one hip rather than the other and that sort of leads to other dysfunctions. And so, it's all interrelated and very, very important to know that the anatomy exists and that when you have a dysfunction, you need to have look at it from a full picture, like, what is exactly going on here? What's the root cause? So, we can correct that and then hopefully everything else will correct itself with time.
Cynthia Thurlow: [00:08:21] Well, it's so interesting to me that in other countries, after women have a baby, they automatically get pelvic floor therapy. And here in the United States, I feel like oftentimes someone has to have a traumatic delivery, like a fourth-degree tear, which is into the rectum, or they have to have significant incontinence before that discussion is even kind of identified. And I'm glad to see maybe younger generations are advocating for themselves and saying every woman actually benefits from pelvic floor therapy. I actually did some last year to help with a tight hip, which we couldn't figure out why my hip was so tight. And the pelvic floor therapist was like, “Oh, we need to do these exercises. We need to manipulate your pelvic floor in a different way. One side is stronger than the other.” And I had zero idea. Even as a nurse practitioner, I had no idea. So, you're absolutely correct that there's a lot that goes on that we probably don't think about until there's a problem.
[00:09:12] Now, be curious to know when you're looking at dysfunction in this pelvic floor. I think many people are probably familiarized with urinary tract infections, pain with urination, prolapse, overactive bladders. In your practice over the last five years, ten years, what are the most common reasons women are coming to you as a clinician to help them figure out?
Dr. Rena Malik: [00:09:34] Yeah, there's a variety of reasons. Very commonly, I'll see overactive bladder, I'll see pain with sex, I'll see pelvic organ prolapse. Recurrent UTIs are so, so common. And sometimes they're not recurrent UTIs and that's the thing. There's two sort of camps, there's the recurrent UTIs that happen because there's actually pelvic floor dysfunction, and they're having pain and symptoms that feel like a UTI, but their culture keeps coming back negative. And sometimes these patients are mislabeled as having something called interstitial cystitis. And that's the sort of a diagnosis of exclusion when we've ruled everything else out that we give that diagnosis, and so that's one.
[00:10:06] And then two is the women who are really getting recurrent UTIs, and oftentimes it's because they're peri or postmenopausal, their estrogen has gone down, and they're now at higher risk for UTIs, and that can be very easily treated with vaginal estrogen topically, twice a week, indefinitely, to help prevent further UTIs. So, I see a lot of that. And then, like I said, pain with sex, pain with-- Just sort of pelvic floor pain or pain that they feel all the time. So, a variety of different things. And sometimes people will come in because, like, “Hey, my orgasm has gotten less strong, or my libido is low.” So, I think all these things come together in a variety of different ways. And the libido and orgasm, sometimes that's related to the pelvic floor and sometimes it's just related to hormonal changes or aging or other factors. But ultimately, people come in for all sorts of reasons.
[00:10:59] And I think, like I mentioned before, you just need to look at it from a big picture and not just focus on the one issue they come for, because they might not know that, “Oh, I have overactive bladder, but, yeah, I'm also constipated. And, yeah, I also have lower back pain. And yes, sometimes it hurts with sex,” but, they didn't even think that they were related. And so, making a big picture to say, “Oh, okay, your pain and your overactive bladder is probably due to this pelvic floor dysfunction. And if you learn how to relax the pelvic floor, align the pelvic floor, do those things with the help of physical therapists, you can improve all these issues without medications potentially, and without maybe invasive procedures.” Now, that's not the case for everybody. Some people do need medications and procedures to get better, but ultimately, again, it's looking at it from a bird's eye view.
Cynthia Thurlow: [00:11:45] And I think it also really speaks to you being a very good historian, you're really taking the time to get a good history from your patients. Now, when we're talking about UTIs, because I do think this is important, how do we define what is considered to be normal? Like, I got a UTI once every six years, or how do we define what is a recurrent true urinary tract infection? And when do you get concerned as a clinician?
Dr. Rena Malik: [00:12:08] Yeah, so the definition essentially of a recurrent UTI is two within six months or three within a year. At that point, we're saying, “Hey, something else is going on here that needs further investigation. We need to do anatomic investigation, meaning make sure there's no kidney stones or incomplete bladder emptying that might be contributing to it. We need to look at a source. You shouldn't be having UTIs at that frequency.” And so ultimately, that is an indication that, “Hey, we need to look a little deeper and try to sort of figure out what's going on to help prevent these UTIs.”
[00:12:39] And oftentimes, like I said, it may be the hormonal changes that occur post menopause or perimenopausally that's starting to affect the ability of your body to fight off UTIs. It can be incomplete bladder emptying. So, a lot of people don't realize this, but even as women, sometimes we can develop the inability to empty fully. And why that happens is because, some people for their whole life, like, a lot-- I see it a lot in nurses. I see it a lot in teachers, in hairdressers who don't have time to get to the bathroom. So, they hold their urine all day long, and they'll go home and they'll feel like they're peeing for five minutes because they've held so much urine. And I'm sure we've been there, but they do that for their whole life. They do it for years and years and years. And over time, their bladder gets used to holding that much and then also becomes weaker and doesn't empty as well. And so, then you develop this incomplete emptying.
[00:13:28] And when your bladder is not fully empty, that urine that's left over becomes food for bacteria. And so, these are sort of things like I tell people, “Go to the bathroom, don't hold it all the time. Yeah. Once in a while, if you're on a long car ride and you got to hold it, I get it, but every day, like if you have a phobia of bathrooms, then we need to work through that or public bathrooms or whatever, but ultimately you can't hold your bladder every single day for hours and hours and hours. It's not normal to urinate once every eight hours. It's also not normal to urinate every hour. So, we have to get you to a normal frequency.”
Cynthia Thurlow: [00:14:00] Well, you already answered one of my other questions was what is considered to be a normal amount of voiding throughout the day. And so, you already touched on that. And for everyone that's listening, when I was an ER nurse in Inner City Baltimore, inevitably when I would be walking to the bathroom, there would be an emergency that came in. And so, I recall there were years and years and years where I just suppressed the need to go when I needed to go. And so, you're absolutely correct over time that can lead to other issues. Are there anything other than treatment with appropriate oral antibiotic therapy? Is there any truth to things like cranberry extract? Can that be used preventatively? We're not talking about cranberry juice cocktail. That's different. That's not what we're speaking to. But what are some of the suggestions you make for women if they're-- let's say they're using vaginal estrogen, they're drinking and hydrating and voiding when they need to go to the bathroom, what are some of the other things that you think are helpful or beneficial for women to understand about prevention for UTIs?
Dr. Rena Malik: [00:14:56] I want touch on the hydration part before I get into the other things. I think that's so important. I think people oftentimes, especially if they've got recurrent UTIs and overactive bladder, they'll tend to limit their fluid intake because they don't want to pee so much. So overactive bladder, just for those of you who don't know, is going more often than you normally do, and that's more than eight times in 24 hours, maybe going more urgently. Got to go, got to go, and you can't delay it.
[00:15:20] Now we all have urge, but when that urge becomes bothersome, like “I got to go all the time. And it's really-- I can't even hold it for a few minutes to get to the bathroom.” Urgency incontinence, so when that leads to leakage and waking up at night. So sometimes when people have overactive bladder, they will intentionally limit how much they drink because they-- “I think, Oh, I'll pee less then.” But what actually happens then one, is it puts you at higher risk for UTIs, but two, that urine becomes very concentrated and irritates the bladder lining. So, the thing about hydration is-- There's actually really good evidence that if you add 1.5L of fluid into your body more than your baseline, you'll reduce your risk of UTIs by 46%. So, it is really impressive how much you can do just by drinking more. So that's number one, first and foremost is really drink more.
[00:16:08] Number two is we got to fix all the other issues that might be contributing. So, constipation is a big one that people don't realize that sometimes when you're constipated that puts you at higher risk for UTIs. So, if you're constipated, we have to treat that. So, whether that means taking MiraLAX or laxative on a more regular basis, eating more fiber, those sorts of things, adding prunes or kiwi to your diet, those things can all help. Seeing a GI doctor if you're not seeing benefit or talking to your primary care doctor, because that's really an important part of it too that we see very often.
[00:16:39] And then if you're not emptying as you mentioned, like you may not know. So, it's important to go see a doctor to actually what they do is they'll have you pee and they'll take a little small handheld ultrasound and scan your bladder to see how much is left. It's really simple, noninvasive. It's just like getting ultrasound when you're pregnant. It's super easy. And so, they do it in the office and they just see how much is left. And so that's really important.
[00:16:59] And then we talk about, okay, what are other lifestyle things? So, one, if you're using spermicides in any way, shape or form, that can put you at higher risk. So, I think it's very uncommon nowadays we don't see a lot of spermicide products, but most people, condoms don't have spermicides in them routinely. So, just making sure that the things you're using, the spermicides could be putting you at higher risk. And then we go to like, what are the other sort of natural? Of course, nothing is better than the other [Cynthia laughs] but sort of options that you can do-- conservative options that you can do to help. So, we mentioned cranberry. So, in the American Urological Association Guidelines, cranberry is an option. And the reason it's an option is because there is pretty good evidence that using cranberry either in supplement form or pure cranberry juice can be helpful in preventing UTIs.
[00:17:46] Now, the things you need to look for when you look for a supplement is that they have 36 mg of proanthocyanidins, the proanthocyanidins or PACs. Actually, what they do is they go into the bladder and they get around the bacteria so that it can't stick to the bladder wall until you pee out the bacteria. And so, they prevent that sticking from happening. And so, you need enough of that for it to actually work. And what they've seen in the studies that 36 mg is the right dose in a soluble form. So, when the supplement says whole berry product, it's actually not a good thing because they're usually using the stems and the skin of the berry. They're not using the actual fruit of the berry. And so, you want to make sure that you're getting the soluble form, 36 mg of PACs, or drink the 100% cranberry juice. It's very unpalatable, [Cynthia laughs] but drink that daily. And that has been shown to be preventative in terms of preventing UTIs.
[00:18:41] And then, I think other things people get very fixated on like wiping front to back and peeing after sex. Now, these things, certainly if you're wiping and you're getting stool going from back to front, that's not good. But otherwise, most people understand, like, I clean my stool before I clean my urine or whatever and they're not going to have issues if they wipe back to front. So, I think one that's like this, yes, if you don't have a problem doing it and you can wipe front to back every single time, great. But I don't want to shame people like, “Oh, you've been wiping wrong your whole life and now all of a sudden, you've UTI that. Oh, is your wiping--” like, no, that's not the case.
[00:19:19] And the other thing is peeing after sex. Now it helps a lot of people. I think it does anecdotally. In the literature, it doesn't show evidence that peeing after sex actually helps UTI. Now people will come at me and say, “How could you say that? You're harming people.” But the other side of it, like, if you're not having UTIs, you don't need to get up and pee right after sex. You can enjoy the postcoital bliss and like just lie in bed for a little bit, it's okay. That's what I’m giving people permission to do. If you're having UTIs, sure, go ahead and pee after sex, it's certainly not going to be harmful.
Cynthia Thurlow: [00:19:52] Well, and I think that's good information to have, especially because I know I certainly was raised in the generation where it was like, “You pee immediately after sex because you don't want a urinary tract infection.” Now, when it comes to overactive bladder, just to finish that loop in that conversation, overactive bladder is something that I saw in a lot of my female and my male patients. And I think for so many of them, they normalized this whole experience. Like I had a parent that had overactive bladder and it took a long time to convince him to actually get seen by the urologist and he got tremendous relief from medication.
[00:20:26] So for you mentioning the fiber, making sure you're not constipated. In terms of medication, like just for a general perspective, when we're talking about overactive bladder, if you get to the point where a patient needs medication, what are some of their options so that if they need to go that route-- Again, we don't want to shame patients. Some people do need medications because urinating 15, 20 times a day is not something that's sustainable.
Dr. Rena Malik: [00:20:51] Yeah or waking up every hour at night is not sustainable. And so, before we get into the medications, there are a couple more lifestyle things that I would add. So, one is making sure your urine is not concentrated. We already talked about that. Making sure you're not constipated-- So, one is [Cynthia laughs] make sure the urine is not concentrated. Two is make sure you're not constipated and three is avoiding bladder irritants. So, this is something that is very personal and individualized, but we know that there are certain things that irritate the bladder lining which make it more likely to have a spasm and that is what gives you that urge to go. And so, we want to minimize those spasms.
[00:21:32] And so some people don't really-- Like, I had a guy who was drinking like four shots of espresso every single day, and then having a second cup of four shots of espresso every single day, cut that back and his urine got better. Now, that's not for everyone, but caffeine is a big one. So that doesn't mean that it has to be through coffee or espresso. It can be through tea, it can be through chocolate, it can be through anything that-- Some of those energy drinks or even the sparkling waters have some caffeine in them. So, I tell people, like, “Don't give up your--" I wouldn't give up my coffee, but there are ways to cut back. Do half caff or just cut back from two cups to one cup just for a little while, just to see if it gets better. And if it doesn't, keep drinking your coffee. I don't want to take away your coffee or your joy from you, but I also just want you to know what your issues are, like, what is causing the problem, so caffeine is one. Alcohol is another one that we know is pretty significant in terms of causing bladder irritation.
[00:22:24] Now, the other ones I'm going to mention are variable from person to person. So, I tell people, when you're thinking about this list I'm going to give you, take one, remove it from your diet for two or three days, take note of your bladder. So even write down how often you're peeing, maybe what you drank and if you have something to measure, you can even measure how much urine came out. That's called a bladder diary. And we use that in practice all the time. You can literally Google bladder diary and you'll find one. You could download it and you could use that and actually take that to your doctor, particularly your urologist, who would know what to do with that. But it's worth, it's diagnostic for us, but also therapeutic for you to look at. Like to say, “Oh, you know, on this day, I omitted this and look at my urine symptoms were so much better. And on this day, I had this coffee and my urine symptoms are much worse.” And then you make an educated decision. You're an adult, you're smart, you know what to do.
[00:23:12] So, the other ones are artificial sweeteners, fruit juices and citrusy juicy fruits, spicy foods, tomato-based products, and sometimes just carbonated beverages on their own. So, some people with this advent of a lot of sparkling waters, were noticing more overactivity. And so, this whole host of different things can affect your bladder differently. And I can tell you, even for myself, there's days where I'll have an extra cup of coffee and I will notice it. I will say, “Oh, I know my bladder is being overactive now because I had that cup of coffee,” but I know what I did and I'll just not do that next time or whatever. And so that's helpful to me because I know what's going on with my body and I can react to it.
[00:23:52] And then if you smoke, smoking is a bladder irritant and also can put you at risk for bladder cancer, among other things, obviously we know lung cancer and a variety of other issues, throat cancer, but certainly if you can quit, that is probably the best thing for your health overall to do that. If you're overweight, we know that losing 8% of your body weight will improve your urinary symptoms significantly. And so, 8% is not a huge number for most people. And so that is something that is relatively doable for a lot of people. So, the general things I tell everyone in terms of lifestyle before we go on to medication.
[00:24:26] And I don't think you have to do one or the other, but I think you should be doing all of it because if you are-- Say you're drinking coffee every day and I give you a medication, it's only going to work so well, because you're still drinking the coffee, and so it's got to go in concert. And for some people, you can avoid having to take a daily medication.
[00:24:45] Now when we talk about the next step in the care for overactive bladder, that would be then going on to medication. And we have two classes of medications that are available. It's something you take every day. Overactive bladder is considered to be a chronic condition, which means that you're not going to take a medication for a month and then things are going to be great, you're going to go off it and you're going to be fine. Usually, we try to find the cause of the overactive bladder. As I mentioned, sometimes it's pelvic floor dysfunction. For men, sometimes it's an enlarged prostate, and so we can correct that issue and hopefully treat your overactive bladder.
[00:25:16] And so, if we can't find a cause, then it is a chronic condition that requires medication. And so, with that, these two classes of medication, anticholinergics are the older class of medications. All the medications work about 60% to 70% of the time, and so you take it. Usually most of the medications are once a day. They do have some side effects. So, anticholinergics have some side effects of dry mouth, dry eyes, and constipation, which is not great. But not everyone has it, but it is relatively common. So, if you notice that, talk to your doctor. Don't keep taking the medication because there's so many other options. And then there is--
[00:25:51] And I want to be very clear this is just an association, but there is some data linking some of these medications with-- associating them with dementia. And so, I try not to prescribe them as much as possible if I can, particularly in patients above 65 years of age and for shorter periods of time. So, we see that link happen around after you've been on it for about three years. So, for a short period of time, it's totally fine to try it. Oftentimes insurance will require you to try these medications first before you go on to the other medications, the beta-3 agonist, because those are still brand name and are more costly. And so, it's not unreasonable to try it, but I wouldn't want to be on it for long periods of time based on this association if I could if the other medications work as well and I can get afford them because sometimes for some people these medications work really, really well and in that case, you have to weigh the risks and benefits. It's still just an association. We don't know causation. It means that this doesn't cause that, but we just see that people for more than three years have a higher risk of getting dementia.
[00:26:51] Then there's beta-3 agonists. And these are medications that relax the bladder and they work by sort of affecting receptors that relax the bladder. So, you don't have that urge as much where the other medications work to help prevent the bladder squeeze. So very similar mechanisms. This one doesn't have those dry mouth, dry eyes, constipation, side effects or the link with dementia. There are some side effects with some of them with blood pressure. So, you need to check your blood pressure after starting. Some of them-- you have to make sure it's okay with certain other medications you're on. And then sometimes you'll get nasopharyngitis where you get sort of inflammation of the nasopharynx passages. And typically, you know that and you feel it and you stop the medication. But for a lot of people, they work fine, they work very well, and people take it every day and they get better.
[00:27:37] But just like I think some people get frustrated because they'll try one, it does nothing, they'll try another one, it does nothing, and they're getting frustrated. One is you've got to take it for about at least eight to twelve weeks to see full effect. So sometimes people give up too soon. And two, everyone's different. And so, I don't-- Yet we don't have the way to, like, look at your blood work and say, “This is the right medication for you, but we don't have that right now.” And so, we sort of have to go through trials of different medications to see what works for you.
[00:28:05] And I think it's important to just be in touch with your doctor and you're like, “Hey, I've been trying this for 12 weeks. I'm not seeing a difference. Can we try something else?” Rather than just being like, “Oh, doc, this is just how it has to be.” And then we move on to interventions that are more invasive. And so, we have three categories of interventions. One is bladder Botox, where we inject the bladder wall with Botox, which is a neurotoxin that actually paralyzes the muscle. So again, it prevents the bladder from squeezing very strongly, so it reduces that urge. All these sort of--
[00:28:33] It's about 80% effective with what I'm going to tell you about next, which is a bladder pacemaker. Both of these are about 80% effective. The Botox does need to be reinserted in the bladder every six to nine months. It lasts a little bit longer than the Botox you might get elsewhere in your body. And so that's a good sign. But it does mean that you need to come back for repeated procedures if it works well. And again, 80% of the time, it works great, and people are really, really happy.
[00:28:57] The one thing to know about Botox is that sometimes it works too well. So, in 5%, so 5/100 people, it works too well. And they can't empty their bladder, meaning they can't pee very well. And so, they might need to insert a catheter to empty their bladder for a short period of time. It's exceedingly rare, but something to know. And then we have a bladder pacemaker, which is an implantable device where we insert a little [unintelligible [00:29:20] next to the nerve root that stimulates the bladder. And this then tells your bladder to sort of normalize nerve function. And so, it again works to reduce the urgency, reduce the frequency, reduce how often you wake up at night. You get a trial period where you have this little wire attached to a battery you wear on the outside side. And if it works, if you see a benefit, then you get implanted battery that goes in the back between your bottom and sort of where you lean against the chair. And so, it shouldn't be bothersome, you won't be able to see, you will have a small scar there.
[00:29:54] There are newer sort of things in development right now where they're not having to implant a battery. Like you might have to just wear an underwear and do that every day for 20 minutes. So, there's a variety of things in this area of implantable nerve stimulation that are coming up. There's some that are getting implanted in the ankle to stimulate the tibial nerve. And that's sort of our next option, which is actually a really sort of nice option. It's just more time intensive. It's called peripheral tibial nerve stimulation. And you put a little needle, acupuncture needle into the ankle that stimulates the tibial nerve. And this nerve goes all the way up to the S3 root, which then stimulates the bladder. And so, you come in, you get this little needle implanted. It's attached to a little stimulator. You feel sort of a tingling, buzzing feeling and do it 30 minutes every week for 12 weeks and then once every month. And so, it's very low risk. It's just time intensive. And so based on the success of that, which is around 60% to 70%, they then now have made implantable devices that you implant into the ankles. You don't have to keep coming into the office to get those done.
[00:30:56] So, there's a lot of stuff here. I just read an article on gene therapy that you inject in the bladder that's currently in trials. So, there's a lot that's going on in this space, which I'm really excited about because we've only had these few options for so many years. But I think that the good news is that people are really-- This is a big problem, 16% of the world has overactive bladder, at least, at least, and that's with leakage and all that. So, some people just have really bad frequency and some people just have really bad urgency and they may not leak. And so, I think it's really a huge problem and something that a lot of people struggle with, so you're not alone, but it is really debilitating.
[00:31:33] You mentioned this earlier, people think it's just normal. And what I think is like, no, this is really not something you have to live with and can be super debilitating. People like, won't go to the movies or they won't leave their house, or they won't be intimate with their partner because they're so miserable with their-- They might even have urge during the middle of sex and they don't want to deal with that, and so it can be really debilitating. And so, I think just realizing that you're not alone and that we want to do things to help and there are things available.
Cynthia Thurlow: [00:32:05] Well, and it's so interesting that this field is becoming even more innovative. And I wasn't even aware of some of the treatment options. Now I just want to pivot a little bit and kind of focus back in on pelvic floor dysfunction. Because I think for many women, I had two C sections, I had two breech deliveries. Pregnancy in and of itself really can impact the pelvic floor quite significantly. When you're taking a history from your patients, I'm sure there are maybe red flags for you, things that might have contributed to a worsening of their circumstances. So, when you're talking about pregnancy and whether it's a vaginal delivery or a C-section, what are some of the risk factors beyond just the pregnancy itself that are maybe red flags for you as a clinician?
Dr. Rena Malik: Yeah. So, one is how big was the baby? So, if you had a really large baby, that puts you at a higher risk for weakening pelvic floor. These things that happen during pregnancy more often cause a weakened pelvic floor rather than a dysfunctional high tone pelvic floor. But the trauma of delivery in and of itself can lead to pelvic floor changes, so that's one. And trauma not being like, oh, it's mentally traumatic, but it's actually trauma, a baby is coming through your pelvic floor. It's actually like your body's responding to having done this by sort of tensing up. But for the most part, most people will develop a weak pelvic floor. So one is, how big is the baby? Two is, was there an episiotomy done? Sometimes that can create issues. Did they have to use forceps? Did they have to use vacuum delivery? Did they have to use anything else that went along with the pregnancy? And then did you have issues right after delivery?
[00:33:39] So sometimes people do have leakage right after delivery or do have more overactivity, and that usually resolves after about three months or so. But sometimes it's really bad for some time, and then things get better, but then later on they get worse. So, these are all sort of things that we look at. We can't undo them. And so, it's more about saying, “Okay, these are risk factors.” And then we do an exam to confirm what we've talked about. But these are all risk factors.
[00:34:04] Anyone, even if you had a C-section, can be at risk because you're still carrying the baby for nine months. And especially if you've unintelligible [00:34:08] before having a C-section, but even if you haven't-- Even if you just had a planned C-section, just carrying that baby for nine months, one, your alignment, your center of gravity goes off when you're carrying a baby. Two, the baby is heavy. I mean, there's a whole bunch of factors, you might change the way you walk when you have a baby. You might change the way you sit when you have a baby. All these things can affect your pelvic floor. And so even if you've just carried a baby and had a C-section, doesn't mean-- and you're fully immune. Yeah, you might be a little less risk than someone who delivered a baby, but it means that there's little a chance that you might have an issue. And just because you had a C-section doesn't mean that you should be like, “Oh, something else is going on here.” You should still get an evaluation and see your doctor to get an exam.
Cynthia Thurlow: [00:34:51] Some of the questions that came in are around people that have connective tissue disorders, so maybe EDS or things like that. Are they at greater risk? I would imagine that they might have a greater degree of pelvic fluid floor dysfunction over time.
Dr. Rena Malik: Absolutely. So, EDS or Ehlers-Danlos syndrome, those patients have really significant pelvic floor weakness, usually, and it can start at even younger ages. I remember having a woman who hadn't had any babies before and she had really bad pelvic organ prolapse because of Ehlers-Danlos syndrome. So, it's a weakening-- It affects your collagen and connective tissues, and so it can similarly affect the tissues in your pelvic floor, so that's one.
[00:35:31] Two is neurologic disorder. So, if you have neurologic disorder, that can also put you at higher risk. Those people tend to have weak pelvic floors. So, for example, patients with multiple sclerosis, they do have weaker pelvic floors and then they tend to do less well with pelvic floor physical therapy because at baseline they don't have the strength in their pelvic floor. Not to say it's completely useless, but to say it's a little bit more challenging. And so, you can absolutely try pelvic floor physical therapy in these cases, but you're going against a condition that is fighting you a little bit. And so sometimes knowing that, like you're going to try your best and maybe you'll be successful, but maybe not, you might need some of those more treatments, medications or procedures that we have available.
Cynthia Thurlow: [00:36:11] And then I think about things like, you know, just coughing in and of itself if it's excessive or lifting heavy or just being of a larger body habitus that maybe those things can also contribute. Obviously, this is your area of expertise, may contribute to more issues surrounding this pelvic floor.
Dr. Rena Malik: [00:36:30] Absolutely. And so, people who do like-- We know that people who are overweight are at higher risk because again, you're carrying that weight all the time, so the muscles get weaker. And similar to how we said in overactive bladder, weight loss helps in leakage due to a weak pelvic floor, which is leakage with coughing, sneezing, lifting, jumping on a trampoline, that happens because of a weak pelvic floor often, or pelvic organ prolapse where you feel like a bulge or sort of something coming down or out of the vagina, those are caused by weak pelvic floor. And so, in those cases where you have a weak pelvic floor, weight loss can help. And so that's one.
[00:37:05] And absolutely, so doing high intensity interval training, we sometimes see people have issues with that. Sometimes when people are like really big weightlifters, which I think is great, they don't breathe well. So, they'll be right there lifting and they’ll hold their breath every single time. And so, yeah, once in a while it happens, but you want to always be exhaling on exertion because that's stabilizing the pelvic floor, so, it can help you carry that load. And if you're not doing that, you're going to be putting strain on your pelvic floor. And that can then over time cause weakness. And so, I think ultimately--
[00:37:36] Yeah, if you have a job where you stand all day long, that also puts you at a higher risk because you don't get to relax your pelvic floor as much as the average person. So, I think there's a lot of things that put you at risk, but ultimately like always keeping a healthy body is helpful and important, and breathing well during your exercises is good and important, so do those things regardless. But I wouldn't say, like, “Oh, I got to change my job because I'm worried about my pelvic floor.” No, you just have to be thoughtful. And if you start having symptoms don't ignore it, that's really the big thing is. I see so many women who for years and years and years, they come to me 20 years after they've had symptoms, 20 years, because they've been so busy taking care of their kids, taking care of their family, taking care of everyone else around them, but they've never taken the time to take care of themselves.
[00:38:20] And even by the time they come to me-- So, I had a patient the other day. She came in and her husband is not well. And so, she's been dealing with these symptoms for 20 years, now she's finally come to me, but her husband's not well, so she's like, “Well, if I have surgery, who's going to take care of my husband while I'm recovering?” So, there's always going to be something. And I think, we have to utilize the people around us, ask for help and put ourselves as a priority, because life's going to be over before we know it. And then we've have struggled for so many years or been uncomfortable or miserable for so many years when we could have corrected it.
Cynthia Thurlow: [00:38:53] That brings up such a good point. I think, because we are the caretakers, we're always focused externally on everyone else. And sometimes it can be very hard to say, “I actually need to prioritize myself. And that may mean I may need to ask for help. That may mean I need to take time off.” And for many individuals, they are truly selfless that they're so focused on everyone else instead of themselves, but we do need to take care of ourselves. The most common issue, where we got the most questions is surrounding incontinence. I think every woman I know, irrespective of where they are north of 35, if I do too many jumping jacks, I will have a little bit of incontinence. And so, I tell people, what do I do? I avoid the things that will actually provoke that. But it's a significant amount of women that deal with some degree of incontinence.
[00:39:39] Can we speak to this because there's obviously different types, there's obviously different ways to address it. But I think this is such a common issue. And again, it's that shame women don't want to talk about it. And I think about my grandmother's generation where my grandmother said “We just never talked about.” And my grandmother was a nurse. I mean, she never talked about these things and they just learned to deal with it. And however, that was, whether that was-- I had a patient that had a potato pessary because of prolapse, which I'm sure we'll touch on, but I think so many women, they just don't prioritize addressing themselves. And this incontinence to me is one of many issues, but this one seems to be the most common one that we see.
Dr. Rena Malik: [00:40:18] Yeah. So, one in three women will have incontinence, one in three. So, guarantee you know someone who has it, they might not tell you about it, but one in three women have it. So, it's very, very common. And so, when you think about incontinence, the most common types are stress and urge incontinence. So, urge incontinence, we've talked about a little bit. It's incontinence that happens when you got to go, got to go and you can't make it. Sometimes it gets so bad that you don't even know and it just leaks out. So sometimes people say, “I don't know, it just leaks out. I'm sitting there and it just leaks out,” that's probably urge incontinence.
[00:40:47] Then there's stress incontinence. So that's leakage that occurs when you cough, sneeze, lift something heavy, sit from standing, even go for walks for some people, they'll leak. And then there's mixed. Mixed is probably the most common and mixed is both. You have both types of incontinence. Now, they're treated differently. The good news is that fortunately they're not dangerous. And that's why I think people are like, “Oh, it's okay, I'm okay, I'm fine. I don't have cancer or anything.” They're not-- most of the time it doesn't mean that something dangerous is going on. I would say 90 plus percent of the time. Yes, there's the rare time where that incontinence either means that you're not emptying your bladder and that can cause issues because you're not emptying your bladder, or it's because the pressure in your bladder is so high, it's going up to your kidneys too, that's very rare.
[00:41:30] For the majority of people, it's just a nuisance. But it's not just a nuisance, it's more than that. It can be very-- It can affect your self-esteem, it can affect your socialization, it can affect your intimacy and it can affect your pockets because you're buying incontinence products. And that really adds up month to month to month if you're buying a lot of them. And so, I think that ultimately one is, yes, like, it's normal in terms of, like, it happens to a lot of people, but it's not normal. It's common, but it's not normal is the right way to say it. So that means that yes, you can live with it if you're not bothered by it and you don't want to-- If you're fine with a little bit of leakage, that happens when you do jumping jacks occasionally that's okay, like that's totally fine. But if it does bother you, there are things you can do for it.
[00:42:12] So, we've talked about overactive bladder. That's basically the same stuff you do for urgency incontinence. So go back and listen to that part. For stress incontinence and for both of them, you can do pelvic floor physical therapy. And pelvic floor physical therapy for stress incontinence focuses on strengthening the pelvic floor. And so, you may have heard of Kegels. Kegels are just one exercise that you can do to strengthen your pelvic floor. And very often I tell people, “Yes, you can do them, you can go online, you can YouTube Kegels, you can YouTube “How to strengthen your pelvic floor,” you'll find a lot of great information. But when you go to a pelvic floor physical therapist, it's like going to the gym with a trainer. And I think it's so important because there's not a lot of guidance on how to do them. No one really knows. And a lot of people are not actually doing Kegels. They might actually be squeezing their butt or squeezing their abdomen [Cynthia laughs] -and they're not actually squeezing the pelvic floor muscles and they're not relaxing them well. And that can in of itself over time create problems if you're doing them the wrong way. Just like if you went to the gym and you didn't exercise the wrong way, you might hurt yourself, [unintelligible [00:43:14] so that's one.
[00:43:17] And then there's no pills or treatments for stress incontinence, weight loss, obviously I mentioned earlier can help with this, but there's no pills. So, you can then move on to what we call pessaries or devices you put in the vagina that can help hold-- They have a knob on them, that push up on the urethra that help prevent leakage, those can help. There're also some devices available over the-- Usually, not often at the grocery store, but you can buy them called like [unintelligible 00:43:45] for example, that has a tampon almost is a little bit bigger sometimes that can help as well, so, there are devices you can use.
[00:43:53] And then there's surgical options or procedural options. So, there is transurethral bulking agents where we go in with a camera and we inject a little bit of-- Usually, nowadays people are using water-based gel, polyacrylamide gel into the wall of the urethra that helps prevent leakage. The nice part about that is there's very little downtime. You can go back to doing all your normal activities very quickly. It works about 70% of the time. And so, it's not a home run. But for a lot of women who are super busy, who don't have the time to take downtime after a surgery, that's a great option.
[00:44:26] And then there's sling procedures. And so, the most common one is using a mesh. Mesh to use sort of as a hammock to hold up the urethra so it doesn't leak when you do those activities. And there's using mesh, there's using your own tissues. And so, you can talk to your doctor about what they offer and the risks and benefits of those if you decide to, but they are very, very effective, upwards of 90% effective. And so, they're good procedures. You do have some downtime, but usually you're up and moving pretty quickly, but we don't want you doing any heavy lifting or strenuous activities for about four weeks at least, sometimes six to eight weeks depending on your individual case after that surgery.
[00:45:04] And so that does require for some people, change in their lifestyle for a little bit of time, and that's okay, you just have to be prepared for that. But they work really well and you can get your life back and you can feel like yourself again and gain your self-confidence and do the activities you were doing before without feeling like, “Oh no. I can't go to my favorite gym class anymore because I leak or I can't ever wear white pants again,” and now you can do those things again.
Cynthia Thurlow: [00:45:30] Well, I think it's good to have a sense of what the options are, both from lifestyle and then surgical interventions if necessary. I do want to briefly touch on prolapse because again, this is another thing that women become very uncomfortable talking about. Not just like a bladder prolapse, but also sometimes you'll actually get rectal prolapses. When you're seeing your patients, I would imagine a bladder prolapse is probably more common, but again, that constipation. Constipation exacerbates all of these issues, but it's helping women understand and bring greater awareness to that so they can facilitate conversations with their own specialist.
Dr. Rena Malik: [00:46:07] Yeah, so we now call them like, based on where the compartment is. But people generally think like, “Okay, my bladder's falling out or my rectum is falling out or my uterus is falling out,” but essentially, just where's the weakness is it at the top of the vagina? Is at the bottom of the vagina? Is it at the apex of the vagina, essentially? And so that's sort of what we're looking at. Some people will have it in multiple compartments. And that makes sense, because if your pelvic floor is weak, it's likely weak in multiple areas. And why does this happen? Same reasons that we talked about for leakage. When you cough, sneeze, lift heavy things, same things can affect your pelvic floor and lead to weakness.
[00:46:43] Now, many people have pelvic organ prolapse. If we look at studies where they examine everybody who comes in, you'll see that, like, I think I forget the number, but it's like-- I don't know, over 50%, I think it's 40% of women have prolapse, but not everyone's really bothered by it. And so, a lot of people have prolapse but it's not coming outside the introitus, so they don't feel it that much. It's not really bothersome, so, then it doesn't matter. If you are bothered-- All of these things, for the most part, if you are bothered, seek help. If you are not bothered, don't worry about it. You don't need it to look a certain way or do something. If you're feeling fine, if your sex life is good, if you're able to do all the things you like, don't worry about it.
[00:47:23] But ultimately, depending on where that pelvic floor weaknesses can be, depending on what we'll offer you. Now, everyone can benefit from pelvic floor physical therapy to strengthen the pelvic floor and weight loss. Those things can help everyone and preventing constipation. As you mentioned, constipation can put you at higher risk of prolapse. So, when you're constipated and you're pushing, pushing, pushing all the time, that can put you at higher risk. Also, if you have a chronic cough, I think I forgot to mention this earlier, but some people have a chronic cough from allergies or something else, if you could fix that that will reduce your risk, because with chronic cough you're constantly having pressure in that area.
[00:47:59] I'll have patients where they'll have a cold, and they’re like, “Oh, my God, Doc. I leaked, so much during that week, and then my cough went away and everything went fine.” And so, same thing if you have a chronic cough, talk to your primary care doctor, like, “Can I be on allergy meds? Is there something I can do to reduce my coughing?” Because your leakage might get better and you might put yourself at lower risk for prolapse.
[00:48:20] So one is-- You can then sort of do these exercises, do weight loss, do all those things that can help. And then if that's not helping, again, don't have any pills yet or anything that can just repair this issue, it then goes on to surgical options. And surgical options, there's a variety of different options depending on where the prolapse is, how bad it is, but essentially it can be vaginally, so they go into the vagina. It can be through the abdomen using robot cameras or little tiny cameras with incisions, a variety of different ways. You can use your own tissues, you can use mesh products, depending on the way you approach the surgery. And there's all sorts of many different options. And so just talking to your doctor about risks and benefits of those and really determining what is right for you, I think the big questions to ask your doctor are, one, “What's the risk of this prolapse coming back after surgery?” And two, “What do you think is the best option for me and why?” Because I think that's always a good indicator of what's going on. What happens if I do nothing?”
[00:49:21] So, when you look at studies, there's actually a lot of people who do nothing and nothing happens. It just stays the same. It doesn't get worse. But sometimes, yeah, it does get worse. And so, I think it's like, 50% stay the same, 20% get worse, 20% get better. So probably some variation there, I think it’s probably 25% and 25%. But, basically some people will stay the same and some maybe a small portion will get better, and some will get worse. And I can't tell you just by looking at you which one that's going to be. And so, I think just making sure you always feel comfortable with your doctor is really, really important.
[00:49:54] I think as a patient, you sometimes feel so uncomfortable because obviously there's a little bit of a power differential. There's someone who has authority and knows more than you and is telling you what they think is right, and sometimes-- A lot of times, actually, I will see people, they just-- This is the right thing and that's it, and that's how the doctor talks to you, and so, you're like, “Oh, okay, you know, if you say so,” but you might not really feel comfortable with that, and you're like, “Do I start over and find a new doctor? I don't have time for this. Do I just go ahead with this?” But I think, stick with your instinct. If you don't feel right about something, like, you are entitled to have a doctor you feel comfortable with, and that you feel like is good. I know all my patients are not going to like me, and I know they're going to go get second opinions, and that's okay. I'm not for everyone, and everyone's not for me. And the same thing goes for other doctors. And I think no doctor would ever feel offense if you went and got a second opinion, there's no harm in that. And so ultimately, that's my big takeaways.
[00:50:51] And then really understand the risks, because people will say it's a very low risk. And I tell people, “Yeah, this is a 5% risk, this is a 10% risk,” but if it happens to you, it's not 10%, it's 100%. And so always understand the risk. Everything you do has risk. Like walking outside, you get hit by a car, like everything has risks, but ultimately just knowing what they are. Because then, like, you are well informed in going forward with the surgery.
Cynthia Thurlow: [00:51:15] And I think that's really important, that patient empowerment piece. I worked for a very large Cardiology group for over 16 years, and part of my job was making sure I matched up the patient's personality to the provider. And I would tell people all the time, I have some patients-- Sometimes it was generational. They just wanted to be told what to do, they weren't going to question anything. And then I had others that had already done a ton of research came in and I'm like, “Okay, who is going to be the best provider personality to match this patient so that it's good for everyone?” But I agree with you, getting a second opinion, asking questions. And you're right, a complication, even if it's low risk, if it happens to you, it's going to be much more significant.
[00:51:55] I'd love to kind of round out that conversation talking about some of the changes that you see in women navigating perimenopause and menopause. A lot of it is changes to hormones that are impacting the way the tissues respond. And then lastly, hopefully, I can invite you back and dive a little bit more into arousal and desire and all these other topics because I could probably talk to you for hours. Talk to me about what's changing in women's bodies in the genitourinary system in perimenopause and menopause. Because again, there's this stigma, there's this shame. Many women don't want to talk about this, but it's so, so important. A lot of things that you're talking about, a lot of the disorders, dysfunctions that you see are magnified with these hormonal changes that occur.
Dr. Rena Malik: [00:52:39] Yeah, absolutely. So, when we think about menopause and perimenopause. Perimenopause is a roller coaster. So, your hormones are all over the place. Some days your estrogen is high, some days it's low. And that can really affect your whole body. So, you might have brain fog, you might have hot flashes, you might have joint pain, you might have like mood changes, you might just feel really volatile, you might sleep not well. And so that's where, hormone replacement therapy can be really, really beneficial for a lot of people. I think also just talking about the lifestyle, like optimizing sleep hygiene. So, making sure you're avoiding screens before bedtime, making sure you're trying to go to bed around the same time, making sure you try to reduce stress in your life as much as possible, exercise, eat right, all those things that everyone tells you are super important.
[00:53:25] But hormone replacement therapy or non-hormonal options are really helpful. We're not going to go into that too much in detail here, but typically during this time you can start getting genitourinary changes. And so, what happens to the genitourinary tract is your estrogen drops really low. And when it drops really low, it affects the tissues of the genitourinary tract. So, your vaginal epithelium becomes thin and more friable what we call atrophy or vulvovaginal atrophy. So, it becomes thin and friable and you can start maybe having pain with sex. You can start having maybe less lubrication. And that means that sex is less enjoyable potentially. You can also notice that your labia or the outer lips or the inner lips of the vulva will actually-- And so, they'll get smaller and so that causes discomfort. Your urethra actually shrinks a little bit. Your clitoris might actually shrink a little bit. And so, all these changes happen because of lack of estrogen. And they put you at risk for things like pain with sex, for things like recurrent UTIs we've talked about, for things like less lubrication.
[00:54:30] And the thing is, when we talk here a lot about menopause and a lot of the symptoms are really a 10-year window where you're going to have these horrible menopausal symptoms and then things get better, but the genitourinary syndrome of menopause occurs throughout. So, from the day you start losing estrogen until the day you die, these symptoms can occur, can get worse, or can stay the same. But you might be like, “I'm 60 and I'm starting to feel these symptoms. I never had them when I went through menopause.” That doesn't mean it's not because of lack of estrogen. It's just that it's taken that much time for them to evolve and show. And so, there are receptors in your vulva, there are receptors in your bladder, there are receptors on the outside of the vulva that are all estrogen and sometimes testosterone sensitive. And so, when we lose the estrogen, it also can cause all these issues, but it can also even affect your bladder, so there's actually estrogen receptors in the base or the trigone of the bladder.
[00:55:26] And sometimes people get more overactivity because of lack of estrogen. And so, one of the things I didn't mention when we talked about overactive bladder is vaginal estrogen can be helpful. Now it's not a home run in terms of, it hasn't been shown to be effective in every single person in terms of reducing overactive bladder, but it can be helpful for a lot of people in reducing urgency, frequency, waking up at night, those sorts of issues with the bladder.
[00:55:51] So, what do you do right? So how do you treat this? And the first thing if you don't want to use hormones, but I will say hormones are very, very safe in the vagina because they don't get systemically absorbed or very little gets systemically absorbed. And so, they don't cause all the scary things you might have heard of that sometimes happen with oral hormone replacement therapy in rare cases. But essentially, nonhormonal options, obviously lubricants. Lubricants are great. I love lubricants. I think everyone should use lubricant. There's water based, there's silicone based, there's oil based, they have pros and cons. The one thing I will just say, if you're using water based, make sure you reapply because it will evaporate. And then if you're using oil based, make sure to not use them with a condom because they will degrade condoms. Silicone base, they say not to use them with silicone toys, but I have yet to see someone whose toy has had an issue because of silicone-based lube. So anyways, not-- Maybe they're not telling me, but anyway, so lube is great.
[00:56:45] You can also get moisturizers, over-the-counter moisturizers. They usually have the same kind of stuff we put in our face cream. Hyaluronic acid, moisturizing ingredients that you just put on the vulva and vagina and they moisturize the tissues. And you can use them every day, every third day. Depending on the formulation, they come in as creams or they come in as suppositories, which is just a pill you put in the vagina that dissolves. And so those are options as well.
[00:57:09] And then we go on to hormonal options. So that brings us to vaginal estrogen, which is probably my favorite treatment for everybody. It comes in a cream, which is probably the most cost-effective way. I tell people throw away the applicator, just put-- Fill your first finger with vaginal estrogen cream and rub it inside the vagina. You don't need to make it go all the way up, mostly around the opening. You could even put it on the vulvar tissue, so around the clitoris, on the inner labia. That is all helpful to sort of make those tissues more healthy. Twice a week, at night, till death do you part, so forever. And that's the cheapest and easiest way to use vaginal estrogen. You can also get suppository so there are little pills that you put in the vagina that absorb. You do those twice a week at night as well. And then there's rings that you get placed at the doctor's office that stay in there for three months and then you take them out and put a new ring in. And so that's sort of [unintelligible 00:57:58] forget it, which is nice.
[00:58:00] But there's all these options that are very safe and very effective. And anyone can have them unless they have active breast cancer. That's really the only contraindication for vaginal estrogen. Otherwise, anyone can be a candidate and they can be transformative, they can really make sex more enjoyable, they can increase lubrication, they can prevent thinning of those tissues. And so that's really, really helpful. And then sometimes we can even use, if you do have breast cancer or you're concerned about estrogen, you can use intravaginal DHEA, which is by the name Prasterone. And so that you can also get prescribed. You can also use-- There's some small data on testosterone, but not readily available yet, not prime time, but sometimes we do use estrogen and testosterone compounded cream on the vestibule for some people where that's an area of discomfort. And so that's something that we would examine. And if we saw discomfort, we could try that to help with any discomfort that you might be having.
[00:58:55] But, I think ultimately there's a lot that happens during that time that can really change your life. And these, we have really effective treatments that can help you. So just don't suffer in silence. Talk to your urologist, talk to your gynecologist, talk to your menopause certified provider that you're seeing and talk to them about these issues because they can be really-- These things are so simple and they're really transformative.
Cynthia Thurlow: [00:59:18] Well, and the one thing that's interesting is when I was looking at the statistics, this whole genital urinary syndrome of menopause, 84% of women, if they live long enough, will experience it. So, it's not a question of if, but when. And I know that for myself, I was telling my husband, just using vaginal estrogen means I never wake up at night to pee anymore. I'm like, life changing, such an easy thing. And I didn't realize that I was starting to wake up with greater frequency. And so, we made some adjustments to what I was taking and I was like, “Oh my gosh. I just realized that adjusting my estrogen just a little bit made such an enormous difference.” So relatively easy things that we can do that are very cost effective.
[01:00:00] I would love to invite you back. I know that you are super busy, but I know there's this whole other-- The sexual health piece that I wanted touch on, but I want to be respectful of your time. Please let listeners know how to connect with you. You have an amazing YouTube channel, you are actively practicing and I saw that you have multi state licenses so I know that you practice outside your home base. Please let listeners know how to connect with you outside of the podcast.
Dr. Rena Malik: [01:00:21] Absolutely. So, I have my own podcast. If you guys like podcasts, check out the Rena Malik, MD podcast. I also put those videos on my YouTube channel and I have a YouTube channel which is the Rena Malik, MD channel where I make content each and every week. So once a week we do a new piece of content that's usually related to sexual health, bladder health, urologic health. And then we have a podcast where we have guests who are experts as well as I do solo podcasts, really like going into the everything you need to know about a certain topic. So, I go into like 30, 45-minute sort of lecture-type thing that really goes into detail.
[01:00:54] So, sort of like we did today on overactive bladder. I basically went over a lot of the stuff that I cover for most of my patients and so it's really helpful. I think you mentioned earlier, like what can you do with the patient? I think like learning, so going online and thank God for social media and podcasting and all these things where you can go on and learn. So, it's just a resource for you guys to learn.
[01:01:17] You can also find me on Instagram, on Facebook, on TikTok, all the platforms as @renamalikmd. And then if you need to see me as a patient, you can check out my website, renamalikmd.com/appointments and make an appointment with me. I have an in-person office in Irvine and Beverly Hills and then I also take virtual patients from seven different states. So, if you are in those states, I'm happy to see you. Or if you're not in those states, I can do an educational visit where I can't actually be your doctor, but we can talk through things and I can teach you whatever you need, whatever questions you ask you can take that back to your doctor or provider who you're seeing and then be armed with the things you want to talk about.
Cynthia Thurlow: [01:01:54] Amazing. Thank you so much for your time today.
Dr. Rena Malik: [01:01:57] You're so welcome.
Cynthia Thurlow: [01:02:00] If you love this podcast episode. Please leave a rating and review. Subscribe and tell a friend.