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Girl Talk: An Expert's Guide to Women's Health

Sometimes, its the exact things that all women have in common that we talk about the least. Take perimenopause for example: it’s the gradual process leading up to menopause that begins years earlier, in our 40s, as a gradual hormonal shift, and you may have never even heard of it. These and other women’s health issues, especially pelvic floor-related concerns, often get less exposure than they should, and that’s largely a feature of a lack of candid, comfortable discussion around women’s health. That’s why we tapped Dr. Rebecca Nelken, LA-based physician board-certified in obstetrics and gynecology and female pelvic medicine. If you’ve ever wondered if an issue was “normal,” struggled with the connection between health and self-image, or wondered how to better advocate for yourself in or out of a doctor’s office, we’ve got the answers.
Rip & Tan: As an expert in obstetrics and gynecology and a female pelvic reconstructive surgeon, what do you see as some of the biggest issues in women’s health that need more awareness?
Rebecca Nelken: Unfortunately there is a stigma surrounding pelvic floor disorders, and women are often embarrassed to discuss their symptoms.

The reality is that pelvic floor disorders (PFDs) are quite common, affecting 1in 3 women, with 1 in 5 having surgery for this at some point in her life. The most common PFDs that I see are urinary incontinence and pelvic organ prolapse.

Urinary incontinence is any involuntary leakage of urine.  This can be associated with activities like running, jumping, coughing and laughing, or it can be associated with a strong urge to void.

Prolapse is when the pelvic organs (bladder, uterus, rectum) bulge into the vagina or even out past the vaginal opening.  This is due to loss of support from the pelvic muscles and connective tissues.

Because no one talks about it, women mistakenly assume that they are suffering alone.  There is a common misconception that urinary incontinence and pelvic organ prolapse are a normal part of aging and that there is nothing that can be done for these. It is so important for women to know that we have a variety of extremely effective treatment options.

I see many women who have been suffering with pelvic floor symptoms for years because they assumed it was just something they had to live with.  After undergoing treatment, they always say they would have come years earlier if they knew how easy and effective their treatment would be.
Rip & Tan: Can you explain what perimenopause is? When does it start, and what should women know about it?
Rebecca Nelken: Menopause is defined as the cessation of menstrual periods, and happens on average at age 51.  Many women don’t realize that menopause isn’t something that just happens one day. It’s actually a gradual decline in estrogen that begins years earlier, in our 40s. This transition is called the perimenopause, and the underlying hormone fluctuations can cause irregular menstrual cycles, hot flashes, sleep disturbances, mood changes and vaginal dryness. This is also a time when bone loss accelerates and cardiovascular risk factors increase due to changes in lipid profiles.

The important thing to know is that estrogen therapy is the most effective treatment for these symptoms and is very safe in healthy women in their 40s and 50s.
Rip & Tan: Beyond the much-discussed postpartum depression that some women experience, what are some less-discussed postpartum issues? How might one recognize if that’s what they’re dealing with so they can seek support?
Rebecca Nelken: Both prolapse and urinary incontinence are common postpartum, as the pelvic floor heals from the trauma of pregnancy and childbirth.  Low estrogen levels slow this healing process and also cause vaginal dryness.

Often these symptoms prevent women from returning to their normal functioning.  Urine leakage or prolapse may keep women from getting back to their exercise routines.  And many are unable to enjoy intercourse due to vaginal dryness, pain or laxity.  This can contribute to depression at a time when women want to reclaim their bodies and their routines, and need the great endorphins that exercise and sex both provide.

We have many non-invasive treatment options to accelerate the body’s natural healing in the postpartum period.  This is already such a complex time; I encourage women to do whatever helps them feel good again.

I recommend that women start with physical therapy, vaginal estrogen, and possibly a pessary.  It takes about 3 months after completing breastfeeding for hormone levels to return to baseline.  If prolapse symptoms are still present at that time, then we discuss further options.
Rip & Tan: As a doctor who deals with urinary incontinence and other issues that many women find embarrassing, how do you think we can lessen the stigma around these topics, so women will be more likely to get the care and support they need?
Rebecca Nelken: Starting the conversation.  Supporting each other.

I always encourage my patients to share their stories- when women open up about common experiences we empower each other.

It’s especially important for women who’ve had positive outcomes to get the word out.  I see women every day who have been suffering for years because they simply did not realize that anything could be done.  I think if women appreciate how easy and successful the treatment options are, they will be more likely to seek out care.
Rip & Tan: How can women going through postpartum issues or perimenopause feel good in their bodies and reclaim their sex and sexuality?
Rebecca Nelken: The most common cause of painful sex is vaginal dryness. This is common after menopause due to a decrease in estrogen levels. This is the same thing that we experience in the postpartum period when estrogen levels are suppressed.

Of course if sex hurts, we aren’t going to want to keep having it! So painful sex can lead to decrease in libido.

There are a number of simple and effective treatments for vaginal dryness.  Vaginal moisturizers and lubricants are available over the counter.  If these are not adequate, a doctor can prescribe low dose vaginal estrogen which works extremely well.  Vaginal laser treatments or radiofrequency such as Mona Lisa or ThermiVa are also good treatment options for vaginal dryness, especially in women who cannot use hormones. These simple steps can make sex enjoyable again, and improve libido.  This can in turn improve relationships, body image and mood.
Rip & Tan: Do you see a connection between self-image and overall health? How does this relationship affect midlife women?
Rebecca Nelken: I am often asked why cancer and autoimmune diseases have become so prevalent in middle age and even young women today.  It is my personal belief that life stress leads to inflammation, and inflammation is the root of disease.

Breathing, exercise and meditation are all proven to decrease inflammation and illness.

Women can minimize health risks by prioritizing self-care.  I want to encourage all women to live their truth and try to find balance in life.  Make time each day for yourself.
Rip & Tan: Of course, this can be a frightening or intimidating subject for many people—what would you say to a woman who might be dealing with one of these issues, but who is afraid to talk about it or to see a physician?
Rebecca Nelken: The unfortunate reality is that primary care doctors do not ask women about pelvic floor symptoms. So it is incumbent on women to initiate the conversation.

The important thing to remember is that while pelvic floor disorders are common, they are not normal.  And there are many treatment options available, so this is not something that women need to live with.  Initiating this conversation is an important part of self-advocacy.
Photos by Martina Tolot