The Hidden Health Crisis Affecting 50% of Women Over 40 with Kim Vopni

All right, Kim, the vagina coach. Welcome to the show.

Thank you. Everyone gets a little giggle when they say that. I appreciate you having me.

Thank you so much. Well, I mean, my last name's Virgin, so I'm used to people giggling about things. How did you get so into the pelvic floor and focusing on this that you would call yourself the vagina coach? I actually don't know.

So I'd love to know. Yeah. It started, I guess I can also trace it back all the way to 6th grade. I saw a childbirth video and that was, very good, you know, uh, birth control. So, but I grew up then with this sort of fear fascination with childbirth, and I, I went home and I looked at my mom differently and all the women in my life. And when my mom told me her birth experiences, where she was of the era where they automatically would do what's called an episiotomy, so they would cut into the pelvic floor, into the perineum, to create space for babies. So it was well-intended, but it was creating major trauma.

They used to do that like for everyone.

Wow. Yeah. And so, so that was just another confirmation that no, I'm not interested in that. And I was also then, as I was growing up witnessing my mom, she eventually stopped running. She had surgery for incontinence. She had chronic back pain. And so there was this picture painted for me that I wasn't interested in doing all of this because I really love exercising and I really love freedom and I don't want to be held back or having surgeries. So then I meet my husband, decided to want to start a family and my sister-in-law allowed us to witness her birth. And that was the first time I had ever seen birth done differently than what we see in media. And so then that was sort of a turning point for me. I was empowered and I said, I can do this. I want to do this. Next year I'm pregnant, asking my midwives, what can I do to prevent tearing? Should I just have a cesarean? Because maybe that'll protect my pelvic floor. And they told me about this biofeedback device called the EpiNo. And EpiNo stands for no episiotomy. And it's a, device from Germany. It was a German physician who saw women in Africa using gourds of increasing size to prepare their perineum and pelvic floor, and he thought, well, that's a great idea, but it's not going to fly in North America, so how can we make it more mainstream? And he developed this medical device, and then my midwives told me about it. I used it, I had a great experience, asked myself, why doesn't everybody use one? I contacted the company and said, hey, could I be a distributor in Canada? And I didn't intend for it to be a business per se, I just thought I'll tell a few friends, I'll make a little money on the side, and there we go. But that was 21 years ago. So that was really the catalyst that got me into this world. And originally I worked primarily with pregnant women and new moms, and really my— who I work with has sort of followed my own journey. So now me being post-menopause, once I started to go through the perimenopause phase, I was recognizing that this isn't just do your Kegels in pregnancy, or here's how you can recover more optimally postpartum. And I was originally known as the Fitness Doula because I trained, I'm a personal trainer, I trained also as a doula, but then working with this perimenopause, postmenopause group, doula didn't resonate so much, so I needed this brand change. And I was speaking to a group of women entrepreneurs at the Mompreneur Conference about 8 years ago, and my talk was how optimizing your pelvic floor can make you a better mompreneur. And I came up on stage and made a joke because all the other speakers there were some sort of a business coach, marketing, strategy, finance. And I came up and I joked, I said, now you have a vagina coach for your business. And so that was kind of this light bulb moment. And I said, all right, here we go. I'm going to step into this really uncomfortable word. And, and that, that's how it started.

I know, because it's like not a word you say very often.

But no, and everybody has to hush-hush it and whisper it.

And yeah, so, well, but here's the reality, Kim. I think most people, if you said, okay, well, what's your, what's your pelvic floor?

What's a pelvic floor?

I watched the funniest lecture, talk at an entrepreneur's event that was mainly men, and someone came up and did a pelvic floor talk, which was interesting because these guys didn't know they had one.

Yeah.

So, I mean, women know they have one, but I don't know that they would know much more than that of like what really it is and what you need to do about it. So maybe we should start there before we start to get into what could be going wrong with it.

Totally. And yeah, and you're right, male and female anatomy both have a pelvic floor. The male pelvis is narrower. The hips are a little bit higher. They don't have a vagina, they don't have a uterus, they don't go through menstrual cycles, they don't have the same hormonal fluctuations, they don't become pregnant and give birth, all of which are major increases for our chances of developing dysfunction. So the pelvic floor muscles, wherever you're standing or sitting right now, if you, and I'll use my pelvic model as well. If you put your fingers on the front, what people refer to as the pubic bone, it's actually a joint there. So that is one attachment point for the pelvic floor muscles. Then if you lift your butt cheek up and you sort of pry the flesh of the butt cheek away, you'll feel a bit of a bony point there. That's your ischial tuberosity. You have one on either side. And then at the back, at the base of our spine, we have our sacrum, that triangular bone. And at the end of that, we have our coccyx or our tailbone. So those are the 4 attachment points for the pelvic floor. So now if this is the model, for those of you that are watching, this is the person lying on their back and you can see this sort of diamond shape and that group of muscles called the pelvic floor is in multiple layers. There's 3 layers. The first layer is primarily responsible for sexual response. The second layer primarily responsible for managing the openings of the urethra, the vagina, the anus. And the third layer primarily responsible for managing, like supporting our organs, the bladder, the uterus, the rectum. It's also responsible for pelvic and spinal stability. So you are a fitness professional like myself, you have heard of core exercise for probably 20+ years, but never has the pelvic floor been incorporated or included in that conversation around what is the core. So the pelvic floor is the foundation of our core, and it also works in relationship with our diaphragm. So it's very, closely tied to our breath. And when everything's working well in that inner core system, we don't think about it. It's also, that group of muscles is inside. We can't go to the mirror and flex like we do our biceps. So we don't see it. We see our external genitalia and we don't appreciate or understand the importance of this group of muscles because nobody's ever told us. And we don't think anything's wrong until there is something wrong. And now it becomes one of the only things we think about because it affects our sex life. It affects, what decisions we make for going out and participating in fitness, going to work, being distracted by, am I leaking? Can people smell? Can they see my pad? Right? There's all these distractions that come in and start to overtake your life. But this, I call it really the foundation, is so, so important. And we deserve more education and information much earlier in life so that we can prevent what we're now gonna talk about, which are the main signs and symptoms of dysfunction.

Yes, I was listening to one of your podcasts earlier with your show. Your show is Between— what is it? It's Between Two Lips or something like this? Between the Lips? Yeah. And you were talking about how everyone should see their pelvic floor therapist once a year. I go, pelvic floor therapist? And full disclosure, like, I had a hysterectomy. None of this was ever mentioned, ever. You know, you have childbirth, you've I was like, never even, never even heard that this was a thing. So I'm glad we're getting this information out. How would I, when I think of pelvic floor dysfunction, I mean, I think what comes to mind is probably like, you know, urine leakage. Like what are some of the different signs and symptoms?

Yeah. Just as a sidebar, hysterectomy, 9 out of 10 hysterectomies are performed for benign conditions. One of the major reasons is heavy bleeding. Another one is pelvic organ prolapse, and hysterectomy increases the risk of incontinence and pelvic organ prolapse. And nobody is told that. And especially if the reason you had the hysterectomy was because of a prolapse, that risk is even further increased.

Oh my gosh. That is so outrageous.

It is.

And so that's not why I had it, but still, that's ridiculous.

Yeah. And I don't wanna take, like, there are times where a hysterectomy is needed. I just am, I hope that the message starts to get to more care providers to please educate women about all that they can do to prepare for that surgery. So train for surgery, train their pelvic floor, what they should be doing more optimally for recovery, and that pelvic floor muscle training now becomes even more essential after your hysterectomy. So you're right, urine leakage. So stress urinary incontinence is one type of urine leakage. And that's what the one that, if you look at the, the companies that are marketing to women about pads and the quote unquote sexy crinkly underwear that you're supposed to put on and feel fine and jump on the back of a motorcycle with a handsome man, that is marketing to us about stress urinary incontinence. So laughing, coughing, sneezing, jumping, exercise, some sort of exertion creates a rise in intra-abdominal pressure. We can't, we don't have the capacity in that group of muscles to close off the opening, so we leak a little bit of urine. Super, super common, very, very treatable, not something you need to accept as normal or just part of aging or part of being a woman. Then we have urge incontinence. This is where you maybe are fine, you don't have any leaks with exercise, but as soon as you hear running water, as soon as you get home and put your key in the door, as soon as you get to your exercise class, you start to get these overwhelming, I gotta run to the bathroom, and you may not make it in time, you might leak. You might have a full release of your bladder. This is, uh, we'll talk about some of the reasons, but very common, especially post-menopause in a low estrogen state. There's many other contributing factors. You can also have anal incontinence. So that's where gas or stool leak out. Much less common, but definitely much more life-altering. You can have mixed incontinence, so you can have a combination of maybe stress and urge, which is a super common combination, or stress and anal leakage. Penile incontinence. And so many people accept that this is just part of being a woman. They're told by care providers, that's just what happens after you give birth. That's what happens when you're getting older. That's just part of menopause. And we see the pad companies telling us that it's just part of being a woman, and we just sort of accept it and we laugh about it with our girlfriends. Then we have the category of pelvic organ prolapse, statistically more common than incontinence. So incontinence is usually somewhere between 30 to 40% of women. Which if you see it in the literature, but that's a lot of people not reporting it either because they think that it's normal.

Wait, 30 to 40% of women?

Yep. And I argue it's higher. That's what the statistics tell us. But again, so many people are, they're not being asked about it. They're not talking about it with their care providers. So they just accept it.

Right. And does that just tend to be women like postmenopausal or is that all women?

All women. And this can happen to people who've never been pregnant. Who've never given birth, who are young, fit, fit athletes. Wow. Then we have pelvic organ prolapse. 50% of women who have given birth will have some degree of prolapse, but women who have never been pregnant, never given birth, can also experience prolapse. So it's not—

I wouldn't know if you had, I mean, I still look at the other one and I think of all the doctor exams I've ever had, I've never been asked. Yep. So.

Same story now. Yeah, never. It should be one of the— it's like when we check blood pressure. I argue things like constipation, menstrual cycle, and incontinence and painful sex should all be kind of part of that regular questions that we have.

That's— my mind's blown. Okay, so over to the prolapse. How would you know if you had a prolapsed organ?

The best way I mean, there are signs and symptoms that could tell us, but I will also say that early stage prolapse is often asymptomatic. And part of the reason why I recommend every single woman see a pelvic floor physical therapist once a year, even if they have no symptoms, is so that we can screen for this. I always equate it to the dentist. I remember being in elementary school and the dentist and the hygienist came to our classroom and they made us chew these pink pills and it was highlighting plaque. And they said, make sure you brush and floss. And we were, got a little, toothbrush kit, and we've, and then we get told that we should go to the dentist once or twice a year. And we've done that our whole life. So if we had that same PR for the pelvic floor, and at earlier we were told, this is what this group of muscle does. These are signs and symptoms that it could be not working optimally. Here's who you go see once you become sexually active, and you will see them once a year for the rest of your life, even if everything seems fine. So just like we see the dentist once a year, go see your pelvic floor PT.

And what would your pelvic floor PT be? Doing? What would they look at?

So they are regular physical therapists who take additional training in the pelvic floor and are then licensed to evaluate and treat beyond the opening of the vagina and sometimes rectally as well. And so they're gonna look at things like your posture, your breathing, your movement mechanics, like any other physical therapist would. They will then also look externally at your genitalia. They'll be looking for skin changes. They'll be looking for signs of genitourinary syndrome of menopause. Or lactation. They will also be looking if there's been any scar tissue. Then with your consent, they will use a gloved finger to pry the labia apart, see if you can accommodate a finger being inserted, because there are some situations where you may not, either from pain or from atrophy. They will assess the tone of this group of muscles. They will assess the position of the organs. They will ask you to cough and bear down to see if there's any descent, which is an indicator of prolapse. They will assess your capacity to do a Kegel. Everybody's probably heard the term Kegel. We also have evidence to show, like, we have evidence to show that Kegels work when they're done correctly and consistently. We also have evidence to show that most people do them incorrectly because we've never been taught. We've never had a pelvic floor evaluation.

I've never been taught how to do one. I have no idea if I'm doing that right.

Right. And so, so most people do them incorrectly. We have it from, from research. So they're going to assess and then tell you if you're doing it correctly or not and give you different cues and different ways to access that group of muscles. So coming back to the original question with prolapse, how would you know if you're, if you're early stage asymptomatic, you seeing a pelvic floor physical therapist could be one thing, but I will also say that symptoms don't indicate the presence or absence or even the severity. So there are people who could have a very early stage prolapse and have crazy symptoms. I feel like something's in my vagina. I have back pain. It hurts with insertion. I feel like I can't empty my bladder or bowels properly. And then there can be other people who have very advanced prolapse where there's a, a visible bulge at the opening or even outside the opening of the vagina. That one they're, they're gonna know cuz they will see and feel something externally. But if it's right at the opening, sometimes people are like, they don't feel anything. They have no symptoms. So we wanna, We want to have somebody evaluate and check us, and ideally also check us in standing, 'cause most pelvic, like if you've ever had a pap or a pelvic exam with a urogyn, you're usually lying on your back, and the position of the organs and your ability to contract and relax is very different compared to when you are standing upright, especially if you're upright against a load as you would be at the gym.

This is ridiculous.

I totally agree. Part of, part of my mission.

I'm kind of, my jaw's on the floor. Like, and I listened to stuff before doing this interview and I'm still like, I didn't hear this piece of it. I'm like, this is unbelievable.

Okay. The other piece, sorry, just to, to add one more thing to make you shocked even more. When you have, when you have a pap exam, we all hate the, the speculum. So we have the speculum that is inserted, they crank it open and then it pushes the walls of the vagina open, basically. And so if there is any prolapse, so a bladder prolapse would be bulging into the front wall of the vagina. In a rectocele, the rectum is bulging into the back wall of the vagina. So when you put a speculum in and you pry it open, it pushes those bulges away. So it would not indicate, like, people are like, why didn't my doctor tell me I just had a pap? But it's two things. They don't see it, but also unless you have presented with symptoms or even been asked about it, they won't tell you. And part of the motivation behind that is they don't want to create a problem when there isn't one. And I argue there's a problem there. Let's intervene early and, and wow.

Because if you intervened early, I mean, it, could you avoid a surgical intervention on this or is this something?

1000%.

Wow.

So I've had, uh, I had a stage 2 uterine prolapse. I've had a stage 2 rectocele. So a rectocele again is where the rectum bulges in the back wall of the vagina. I also have an early stage bladder prolapse. I've given birth vaginally twice. I've had a birth injury called a levator avulsion, which happens in upwards of between 18 and 30% of births, also never screened for.

And so how would you know that you had that?

You don't, nobody tells you. So that's where part of the muscle has actually pulled away from the bone. And up till now, it hasn't even been any sort of surgical repair for that. Very life-altering. So, The early stage prolapse, which is like stage 1 to 2, we can definitely prevent it from getting worse. We can improve it. We could maybe even reverse it. So I reversed the stage 2 uterine prolapse. I know many people who've reversed stage 1, stage 2 uterine and bladder prolapse. Rectoceles, very tricky to reverse. I don't know anybody who has completely reversed one. That one I did choose after 9 years of trying absolutely everything, I did choose surgery for that, but surgery should, it can be great. It can be an option, but it is presented as the only option for so many people. And they don't, they haven't been to pelvic floor physical therapy. They haven't tried all the different things that like they haven't addressed constipation. They haven't addressed their posture. They haven't addressed their breath. They're not doing pelvic floor muscle training properly. And so many hysterectomies, so many pelvic surgeries in my opinion could be avoided if we had this information ahead of time.

This is crazy. Why wouldn't it be that every OB-GYN would have a pelvic floor therapist in their office with them?

Why wouldn't that make sense?

Why is that not a thing? I'm completely perplexed.

Yeah, there are a few clinics where they do that, but it is not the standard of care. In, in many parts of Europe, pelvic floor physical therapy is automatically prescribed to every single woman who gives birth. I, I would argue it should be prescribed to every single woman regardless whether they've given birth or not. In Europe, it is accessible for any woman, but it is an automatic prescription for people who have given birth. So they have 6 to 12 visits subsidized by the government postpartum for pelvic floor rehabilitation. That should be standard of care across the globe.

This is amazing.

Yeah.

Okay. So we talked about, uh, organ prolapse and the obvious, like, you know, peeing. Are there things that— symptoms that you would— I mean, either no symptoms whatsoever or symptoms that would seem like this couldn't possibly be related to a pelvic floor issue?

Low back pain. 95% of women with low back pain have some form of pelvic floor dysfunction, and they may be seeing chiropractors or physiotherapists, like regular physiotherapists, acupuncture, massage, and all of those can absolutely play a role. I don't want to discount that, However, so often the missing link is the pelvis and the pelvic floor and tightness in that group of muscles. If women are leaking or if they have urges and they're, they're afraid of leaking, they're afraid of not being able to make it to bathroom in time. If they feel vulnerability, like something is going to fall out of them in organ prolapse, they're unconsciously guarding. So their pelvic floor is always on high alert and they don't necessarily know that they're doing that. But their muscles are very tense. When we have tight muscles, we don't have good blood flow and circulation. We— that range of motion is very restricted, so we can't generate as much power. The muscles become fatigued, so they can't react at the right time. We need good reaction time and we need appropriate level of contraction to prevent leaks from sneezes, to support the organs. And if we're in that chronically tight position all the time, that's going to create pain. Could be pain with intercourse, could be constipation. Constipation is another one that so many people don't poop well, and we're chucking fiber in there. We're doing, we're taking supplements, we're doing all the things, and sometimes it's tightness in the pelvic floor. And if the muscles are not relaxing to allow poop to come out, we're straining. That's also going to create more challenges with prolapse, and it's also going to make you feel like you need to go to the bathroom more often. So the first two things that I address with people, constipation and hydration, because the other thing that happens is women who are afraid of leaking, who are afraid that they're going to have an urge with no bathroom, is they start restricting their fluids. If I don't drink anything, I won't have to leak, or I won't leak, or I won't have to go to the bathroom. But now we've got, they're going to be more constipated because they aren't hydrated enough. And also that urine is going to become a lot more concentrated. It's going to irritate the bladder and the bladder is going to signal you more frequently and more strongly. To get it out. So we have to get those two in check first.

Is there a way that someone could self-identify that they were, had pelvic floor tightness, or is that something that you would need to go see someone to get a diagnosis of?

Well, you can sort of self-assess. So if you have, if you sit down, like you get an urge to go to the toilet, urination, you sit down and it takes a while for it to start the flow. That's one indication. If you sit down and you go pee and then you stand up and a little bit more dribbles out, that could be an indication. If you have pain with insertion, tampons, menstrual cups, toys, fingers, penis, feels dis— uncomfortable, that could be tightness. Low back pain, pubic joint pain, hip pain, knee pain, those are, I would say, the more common ones. Or if even just on your own, if, in trying to insert your own finger, if that feels uncomfortable, or if PAPs have always been, I mean, PAPs are never comfortable, but if they are excruciating, that could be another reason. But constipation, always feeling like you're running to the bathroom and having urgency, that people think of that as I have a weak pelvic floor, which yes, tight is weak. So it can be confusing.

Wow. And I would assume that menopause just makes this worse.

Yeah, 1,000%. So we have a few different factors there. A big one is the change in hormones. So a low estrogen state is going to exacerbate symptoms of urinary urgency, urinary frequency, burning, itching, irritation, pelvic organ prolapse. So there's a whole category, there's a whole term, genitourinary syndrome of menopause. There's a newer term also, genitourinary syndrome of lactation, which anybody who is in the postpartum phase in that low estrogen state after you've given birth, that's mimicking what is going to happen when we reach our menopause and we are in that low estrogen state. But that's not the only thing. So yes, estrogen, crucial role for maintaining the juicy, supple state of our, our vaginas. The strength of the muscles, the ability to build muscle in our pelvic floor. But we also have faced aging, so we've faced age-related muscle loss. We have bone changes. We also lose more Type 2 muscle fibers, which are the quick contract-release fibers, post-menopause. And so those are the ones that we really need to have, uh, active when we are coughing, sneezing, laughing, jumping, doing all the things where we want to stop those those, uh, those leaks.

And I think about this and I think, well, so, you know, the less you do, the less you can do. Yep. And so these things start to happen. So people do less.

Mm-hmm.

And then it gets worse. So they do less. And yeah.

Wow. 46% of women will stop exercising because of their pelvic floor. And some are, some are told not to— don't lift anything over 10 pounds, don't run, don't jump. So they're— they avoid or have now limited impact. So now we're thinking about what's happening with their bones. We know the stats post-menopause from a bone health perspective. So that's going to be increased or exacerbated. We are— then they're told not to lift anything. And so now we're not resist— doing any resistance training. So we're accelerating that age-related muscle loss. And a lot of it is, there's some, I would say that happens in the incontinence world, yes, but it's also, it's more so, I would say, the women who have pelvic organ prolapse. Symptoms can stop them because they feel vulnerable. They feel like something's gonna fall out and they feel like this is gonna make things worse. But there was a really interesting study done by Dr. Laurie Forner. It was a subgroup of a big study, close to 4,000 women, and there was a subset of that group of women who identified as having pelvic organ prolapse. And they looked at, well, resistance, like lifting, and they took a light load under 15 kgs, moderate, and heavy over 50 kgs. The women who had prolapse who lifted greater than 50 kilograms had fewer prolapse symptoms. So it's not indicating like, is it, is your prolapse better or worse, or is it creating a prolapse or not? But we know that building muscle And being able to train the pelvic floor to withstand load is helpful in symptom management. So my kind of big message is get the pelvic floor working optimally so that you can jump, so that you can lift. If we are telling people to stop lifting, to stop running, to stop jumping, you and I both use the term powerful aging. There's nothing powerful about stopping exercise.

So what are the causes of everything from all the pelvic floor dysfunction to the actual organ prolapse? Is it, I mean, is it just kind of luck of the draw? Is it the way our biomechanics are? Is it hormones? Why is this so prevalent?

Pregnancy and childbirth are very well-established, very strong predictors. And we know the majority of women do become pregnant and give birth. At some point in their life. But chronic coughing, chronic constipation are also big triggers.

So constipation can, it can cause constipation and constipation can cause it.

Yep. And constipation. So if you're straining to poop every single day, you're literally not getting the shit out. So you're not getting your hormone, like all the stuff and toxins we need out. So you're going to feel like SHID as well, but you're also— you, you— that mass that's in there increases urinary symptoms, and then you're straining to get that out, so you have that downward force and pressure on your pelvic floor. And sometimes it's because the pelvic floor muscles aren't relaxing, so it's— you get into this chicken and the egg scenario, which is why working on not just— like, if we think about people are like, okay, well, I have all these symptoms, so I'm going to strengthen my pelvic floor and I'm going to do Kegels, But if the problem you have is because of tightness, adding more tone is not going to serve you, at least initially. And so, so pregnancy, childbirth, chronic constipation, chronic coughing, poor posture. So we know that women who have more forward rounded shoulders and who lose their lumbar curve, so if you can think of a pelvis that's in a posterior tilt, have an increased risk of pelvic organ prolapse. Ehlers-Danlos, like connective tissue disorders, aging. So just the fact of being older, um, more times giving birth, vaginal will be an increased risk compared to cesareans, but cesarean birth doesn't make you immune to pelvic floor dysfunction. Hormone changes for sure. So especially into that perimenopause, uh, menopause transition, hip osteoarthritis, hip replacements, Chronic heavy lifting. So if we think of chronic occupational mail carriers, for instance, but we also do see people in like powerlifters and CrossFit athletes where there's high load, high repetition, high pace. That can also be a challenge as well. And so the challenge that I'm seeing now with all the information from the explosion of menopause about lift heavy shit and, you know, jump and Dr. Vonda Wright's work, which I absolutely agree with, but I think we have to get the pelvic floor optimized first and then progressively load.

I am just listening to this going, you know, hip replacement, never a conversation about this, you know, um, hysterectomy, never a conversation, childbirth, never a conversation. My guess is that this is so underdiagnosed. 1000%. That these statistics are so much higher. Yep. That it is crazy. I actually started to Google pelvic therapists near me because I was like, is there like, are these people around? Never has anyone even recommended even checking on any of this stuff, which is crazy. Then you look at, I'm thinking about even UTIs and when you have a UTI postmenopausal, what's the recommendation? Oh, take medication before you have sex or right afterwards. That'll do. I was like, but that— wait a minute, hold on. So I know that you're a big fan of estrogen cream because I'm assuming that low estrogen is just going to compound the problem. Yeah, but that the problem likely was still there for most people and then it just gets worse. So maybe they finally identify it. So let's walk through because I don't know how much someone can do on their own? I know that you have courses. Or at what point should you go see a pelvic floor therapist? It sounds like everyone should go run to the pelvic floor therapist anyway, no matter what. Like, like, I'm literally going, all right, I'm going to go book an appointment. I— this is crazy. Yeah, never even— and I would have thought, Kim, I will be completely honest, that I'm a fitness person and, you know, I had easy childbirths. I didn't even have didn't have episiotomy. I just like literally, first baby was the second contraction. And then next one was the first contraction. It was like, push, stop pushing, you're done. I was like, okay, what's the big deal? Why are they screaming down the hall? Never really thought about any of this kind of stuff at all. And you know, this is crazy.

Yeah. And when you think about statistically, 50 to 80% of women will experience one or more of the symptoms under this umbrella term of genitourinary syndrome of menopause. So I'm gonna get to your estrogen point. Genitourinary syndrome of menopause is a collection of signs and symptoms that affect the genitalia. So we have genital symptoms, we have urinary symptoms, we have sexual symptoms. So we can have changes to the external genitalia. We can lose the inner lips, like our inner labia, the labia minora. They— they—

Yeah, I just heard that. When I was doing Tamsen's World Hottest Menopause Party, one of the gals was talking about the fact, I go, what? What happens?

You know? Yeah. Yeah. And the, the hood of the clitoris can, can literally adhese over top the intro, the entrance to the, like the vagina itself. The walls can literally close. That's very extreme, but that these changes can happen when there's no attention paid, there's nobody checking in on us. We are kind of disconnected. We aren't using estrogen. So we have the changes to the genitalia urinary. We talked about, Urinary urgency, frequency, burning, you know, prolapse, incontinence, like all that, anal incontinence.

Where do UTIs fit in?

UTIs, that's, yeah. So that is a big one. And when you think statistically of how many women are going to experience this, there's a lot of people who've been maybe struggling with UTIs for their whole life. Maybe they've just started now that they've reached their menopause and the gold standard, well-established in the literature is vaginal estrogen. And I hear every single day, even though they're, like, I can't even tell you how many articles there are, women are still prescribed recurrent antibiotic after recurrent antibiotic. Nobody has offered them estrogen or even vaginal DHEA, which is also now another research study just came out showing that it can also help reduce that risk. UTIs can be life-threatening. Like, it can become septic, Urosepsis, it's called, and it literally can end people's lives. So when we know how many people will be dealing with at least one of the symptoms, with UTIs being high on the list, let's come in and prevent. Let's not wait until we have all these symptoms to now come in and treat. This is a very safe, very effective, very low dose estrogen, natural bioidentical estrogen. We can prevent so many of these changes. Then we have the sexual piece. So pain with insertion, difficulty with arousal, can't climax. Now we're taking out the pleasure component. How many relationships are breaking down because of pelvic floor dysfunction? I argue pelvic floor physical therapists can literally change marriages. So vaginal estrogen, to me, I consider it like an essential nutrient. It's very safe, even for people who have a history of breast cancer, even for people being treated for breast cancer, breast, cancers of any kind. It's well established. Now, disclaimer, I am not a doctor. However, Dr. Kelly Casperson, Dr. Rachel Rubin, Dr. Amy Killen, Dr. Corinne Mann, please follow them. And I wanna highlight something called their, the FDA has a class labeling for estrogen. The vaginal estrogen insert the majority, like a huge majority of women are prescribed vaginal estrogen and then don't take it because of that label. It scares the pants off you and it is not medically accurate. So there is a whole campaign called Unboxing Estrogen at letstalkmenopause.org. I invite you to go there and help the FDA change that so that it is medically accurate information so women can get the help that they need.

It's like the California laws where they make you post things on, on your shake saying this has heavy metals. I'm like, yeah, but the one oyster you ate had 10 times the amount.

You know, exactly.

It's just crazy.

It's crazy.

Oh my goodness.

Wow. And that's also like, it's so the UTI thing reduction, that's a big piece of it. But it's also, you know, we, we talk about This is a group of muscles like the rest of our body, and you and I are very, we work out, we're working to build muscle, we're working to offset age-related muscle loss. The pelvic floor is not immune to these changes, and we need estrogen to help us build muscle and to help us not lose as much bone. Think of how much bone I just showed you in that pelvis that we have, the hips. So we need estrogen vaginally, and I argue also systemically as well, so that all the things we're doing from an exercise perspective are going to have, that we have the tools from, or the nutrients from the food, but also the hormones that we need in order to get the change or the response in the body that we're hoping for.

I think what's important there is the both, because I hadn't, until we were sitting down at dinner and you dropped that bombshell about vaginal estrogen and UTIs, It's like total dinner conversation. Yeah. But I was thinking, gosh, you know, all these hormone docs I've been working with, and no one had ever talked about vaginal estrogen. The only time it was talked about was if you couldn't do topical, not in conjunction with, and never in relationship to UTIs. So it's like, now I'm using patches, vaginal, face. It's like You got it covered.

Yeah.

Yeah. So I think that's important because I don't think that's out there that much. And again, all I'd ever heard was it was in replacement if you couldn't use systemic. Someone listening to all of this, I know you have an ebook for them, but what are some of the things that they can do right now? Because I think you also have courses. I would assume one of them is find a local good physical therapist who specializes in pelvic floor and go get your annual done to make this a thing. But what, what are the steps?

Always, that's my first recommendation. Please go see a pelvic floor physical therapist. You can Google pelvic floor physical therapy in your closest major town or city. Pelvicglobal.com is also, uh, that is a pelvic floor physical therapist who has a directory. It is a paid directory, so it's not going to be an exhaustive list of absolutely everybody, but it is, it is global. So you can check that directory out as well. Make an appointment. I will say many of them have 4 to 6 to sometimes 8, 12-week wait lists because we don't have enough of them. And now a lot of people are becoming more aware of this, so they're now taking action. But, but it is— I consider you will learn so much about your body and you won't believe that you've lived for X number of years. So that's always number one.

It sounds like an awful thing to go do, I will tell you.

Well, because we think about PAPs. When we think of a pelvic exam, we think of a PAP. And that is not comfortable. It is totally, completely different than a pap. There is no speculum involved. You will spend a length of like usually about an hour and they will do detailed health history. They will look at your posture. They will look at your breath. They will, they will look, you know, what's your meaningful task? What are you hoping to do? What symptoms are you struggling with? And then there will also, maybe not on that first appointment, but there will be an internal evaluation with your consent. Maybe there's scar tissue that we need to mobilize. Maybe there's one side of the pelvic floor that is more active than the other, and we need to rebalance that. Maybe constipation is the issue. Maybe the displacement of organs is contributing to your symptoms, so we need to release some fascial adhesions and scarring, as I mentioned. So there's lots of things that we can address. Then we can— that person will be sent home with the kind of carrying on the list of what we need to do. So we need to pay attention to how we hold our skeleton. Our muscles adapt to how we hold our skeleton. And if we chronically are hunched over, if we're chronically tucked in our pelvis, that's going to exacerbate symptoms, going to create tightness in the pelvic floor and not allow that core synergy to work optimally. We want to poop really well. So working with maybe a gastroenterologist, but sometimes even just increasing your water intake. I recommend 2 to 3 liters of water a day, making sure you're getting enough fiber with a diverse, uh, diverse types of fiber as well. And then you wanna look at your exercise. So we need resistance training, we need loading, but we wanna optimize the pelvic floor first. And so we need to connect the pelvic floor with the breath. Inhales are where the pelvic floor lengthens, exhales are where the pelvic floor contracts and lifts. If you've heard of a Kegel, you may know how to do a Kegel, you may not, but cueing and visualization can be helpful. So things like, I always say, try to imagine picking up a blueberry with your vagina and your anus, or imagine you have a tampon that's slipping out and you wanna pull it back in. That's an activation cue that you would do with your exhalation. Once you've got that connected, we wanna now train the pelvic floor dynamically. The limitations of Kegels is they've always been, you know, 3 sets of 10, 10-second holds done 3 times a day. And people do them standing, people do them seated or seated at every red light, but that doesn't translate to being able to, lift weights, stand up from a chair without leaking, push a heavy door open. So we need to take that Kegel, bring it into whole body movement and train the pelvic floor dynamically and then progressively load it just like we do any other muscle group in the body. Um, sleep is important. Stress reduction is important. Hormone therapy is important. So it's not just about Kegels and I have a program called the Buff Muff Method and people come in and they think they're gonna get all these exercises.

You just leaned into this completely, didn't you?

Just, um, I, I mean, obviously I'm the vagina coach. I, I'm very much pro use of anatomical terms, but it's a heavy topic. We need to have some fun too. Yeah. So great. Yeah. So the, so in the Buff Muff Method, we, we learn how to connect with the pelvic floor, how to layer it into movement. And people come in thinking they're going to just get all these exercises thrown at them. And yeah, there's exercises in there, but I also talk about how to release tension, how to breathe properly, how to poop, how you, what posture you should have when you poop, what optimal posture is throughout the day. All these other things that are influencing. We didn't even talk about bladder irritants. What sort of things are you consuming in a day that are contributing to your symptoms? Coffee, alcohol, artificial sweeteners, gluten for many, dairy for many, Spicy foods, carbonated beverages, acidic foods, very well-established bladder irritants. Not for everybody, but if you're consuming those, then, and you're having urgency, how about if you stop those, what happens? And so we go through all that. So it's very much a diet and lifestyle and exercise approach. It's a holistic way to address the pelvic floor. It's not like people get the blanket statement of go home and do your Kegels. Yeah. And then, and then not told how to do them properly, not had their pelvic floor evaluated, and not told all of the other things that could be potentially contributing to their symptoms that they can address. So there's a lot we can do on our own.

Okay.

Yeah. There you go.

I, I'm, I'm, I will have gone to the, uh, to the pelvic floor specialist by the time, uh, by the time I see you. Okay. Now I know you have an ebook that you're gonna be gifting everyone as well. What is that about? What will they find in it?

It's called "The Inside Story," and it, when I wrote it, it was meant to be short and sweet, to the point, the major life stages that we as women go through and how it influences our pelvic health. And then also tips and techniques and tidbits from pelvic health professionals around the world, because I want people to understand that there are, there, it doesn't even have to be a pelvic floor physical therapist. It could be, for instance, my naturopath has also trained in the levels that pelvic floor physical therapists do. So there are other professionals who have training in the pelvic floor who can help you. And so I wanted to kind of highlight that these are all the people, you might learn something from this tip, that person might also be, be in your neighborhood and maybe you could reach out to them. So it, it, it was kind of highlighting what is the pelvic floor, What are the common signs and symptoms of things going wrong? Here are the major phases of life that we go through, and here are some steps that you can take to help, help make change. I think so many people suffer in silence, and a big part of my mission is to end that and to— I've stepped into this uncomfortable world, vagina, and get more people who, like you now, who will be taking action, saying, okay, I'm going to go. Kim said I'm going to do it. And they come back. I hear every day women like, I was afraid. I didn't want to go. I hate paps, but they come away from that and they say, I cannot believe what I've learned. I feel so different. I feel so much more in power because they feel like they now have something they can do rather than just waiting for a doctor to say, you need surgery. And then they have that surgery and the recurrence rate after pelvic surgery is really, really high. And I think because we haven't addressed constipation, we haven't addressed posture, we haven't addressed the way that they're lifting and they're not doing pelvic floor exercise. So, so let's change that. Yeah.

And I did hear you walk through like your morning, you know, we all have our morning routine and yours, how you incorporate this into your routine and your working out. Cause it definitely sounded very different than what I'm doing.

Yeah. Well, that's the thing too. Like the whole point of the Buff Muff Method is to bring this into workouts that you're already doing. If you're, if you're doing yoga, if you're doing Pilates, if you do weight training, once you understand how the pelvic floor should be working and how it synergizes with your breath, you can bring that into your workouts. Now, that doesn't mean that we should always have to think about picking up a blueberry every single time that we're lifting a weight. We should be, we're training the pelvic floor to remember how to respond at the right time with the right amount of force. But there are certain situations, maybe maybe certain times during your menstrual cycle, maybe after a certain number of repetitions where you want a little bit of extra activation. Deadlifts are really well-established and squats are fairly high likelihood of leaking for people. So let's learn how we can do that with, maybe we add voluntary muscle activation, maybe we change our load, maybe we change how much, how many reps or sets we do. But so my morning incorporates— I do everything the previous day to make sure that I get enough sleep, that I am hydrated, that I have a great poop in the morning. And then I do something called the Hypopressive Method, which is really what helped me reverse my organ prolapse. I do that pretty much every single day. I end with a little bit of like a pelvic primer where I'm activating and relaxing my pelvic floor with a few different types of movement, get some mobility in there. Then I'm going and I'm fueling. And then I, at some point I will have maybe a workout in that day where I might add a little bit more pelvic floor activation and relaxation under load with diversity of movement. But it doesn't need to be this whole other thing. Like I work out already and I do yoga and this, it doesn't mean that you now have to have a whole pelvic floor routine initially. Yeah. But that then becomes part of, part of whatever you're doing.

That's good to know. One more thing that just came to mind because I have it sitting on my counter down below. When I was at Tamsen's Hottest Menopause Party, we as the speakers got gifts, and one of the gifts I got was a Joylux. So what role do these types of— what, first of all, tell everyone what it is and what kind of, you know, how, how do these help?

Yeah. So typically from a, from a device perspective, I get asked every single day, what about the biofeedback devices? What about the Joylux? What about the EMSELLA chairs or the Kegel chairs that we're sitting on? And I'm, I always say, take that money first and put it towards a pelvic floor physical therapist so you understand the status of your pelvic floor. And then if, and what type of device, if a device will be helpful, And then what type? The Joylux device is probably hands down my favorite one because I'm a huge fan of red light therapy. I was their first Canadian distributor way back, like 10+ years ago when they were first coming to market. So I've been using this product for a really long time. Basically, it, it is, it looks like a big white dildo, to be honest. And it has a little window.

I haven't opened the box yet.

So, okay. Just wait. So. It can be a bit intimidating for some people, but it has a little portion of it that has almost like a window where the red light will be emitted from. And so it is inserted into the vagina and you, you turn on the red light. So the red light is then influencing the tissues externally and internally in the vagina and the vulva. And it helps increase collagen. It helps increase, increase, it helps with lubrication. So especially from a post-menopause perspective, I will say though, if you are years post-menopause and you are experiencing pain with insertion, it may not be the device that you start with. There are some smaller ones, or you may start with dilators and pelvic floor PT first, or red light externally before you can accommodate something being inserted. But it basically, it uses infrared heat, red light, and vibration. And vibration, people automatically think pleasure, and yes, that could potentially play a role, But when inserted, when you turn on the vibration, it can help elicit a relaxation response. So people who do have overactivation in their pelvic floor, it can help downregulate that. It helps with blood flow and circulation. And then also when you think about vibration training, so those vibration plates that we stand on, the same, it's recruiting more muscle fibers. And so if we were then to do our pelvic floor activation and relaxation in the presence presence of that vibration while it's inserted, we can arguably— this isn't research that they have, but there you will be recruiting more muscle fibers and people get a little bit more biofeedback when they're doing that. So I'm a huge fan of that. However, I wouldn't say it's where I would start somebody. Always put your money first to pelvic floor physical therapist. And then I'm— I don't like to outsource the work that we can do. So the Kegel chairs that are, they are all over the place. And I want to say that they can absolutely play a role for people who have mobility challenges, spinal cord injuries, nerve damage. But if we are able-bodied, we should be doing the work. The thing I like about the Joylux though, is it's addressing the tissue as well as the muscle, but it's the, the red light is also coming in and helping with that elasticity. That collagen, that lubrication that especially post-menopause we struggle with.

Nice. I'm very excited about this. Shout out, Tamsen. Thank you. And thank you again. I'm going to put everything at jjvirgin.com/vopni. V-O-P-N-I. I was going to do vagina coach, but I think I'll just do your last name. So V-O-P-N-I. And we will link to your ebook. We'll link to your podcast. Website, everything else, so everyone has their resources. And that one website you said that was a directory, because that's important too. I'm pinging my local docs to see if they have referrals here too, because we actually have a lot of pelvic floor therapists.

Who knew? Yeah, yeah, you'd be surprised. You'd be surprised. And I always say, like, even, even if you have to travel, even if it's just one appointment that you can get to invest in yourself and make that appointment and, and go, even if there's not somebody right in your local hood. It literally will change your life.

Well, especially if it's, if it's a once a year thing.

My gosh. Yeah.

Yeah. So thank you. This has been amazing, crazy informative. I, my, I was still so shocked at dinner, and then I got more than I was listening today, and I'm like, oh my gosh, this is just incredible information. I'm super, super honored to have you on the show and so glad you're getting it out there.

Yeah, well, thanks so much for having me, and that's— that's— you're playing a huge role in helping get the awareness out and, and helping educate people. So thank you so much for having me.

Yay on both of us!