By Nicola Reid, Media and Health Content Writer
Sometimes you just need someone to help you connect the dots and this is exactly what Dr Payam Nikpoor did for me. As a woman navigating the often weird and bewildering transition that is menopause, I just needed to understand the mechanisms behind what was happening to me.
Dr Nikpoor is a warm and gentle man who has profound insight, experience, and empathy for women and the many challenges they face across their life span. He has particular sympathy for the impact menopause can have on a woman's confidence and self-esteem and believes that as a society and community greater awareness of what women are experiencing through menopause may bring more compassion and understanding.
Dr Nikpoor, who insisted I call him Payam, was very generous with his time and his knowledge and had a way of conveying information clearly. He was also completely relaxed with discussing many of the more challenging and potentially embarrassing symptoms menopausal women may experience and easily instilled confidence that there is help and support available.
He says, "many people see menopause as an incident, when it is really a transition from one stage to another stage. It is, however, a very big process in a woman's life and awareness of what women are experiencing is really lacking in our community."
If women have more information and understanding about the menopausal transition, they can be better prepared. Whilst the symptoms a woman experiences may be uncomfortable and at times baffling, at least she will understand what is causing them. As they say, knowledge is empowerment and enlightenment can be liberating.
Here is the conversation with Dr Payam Nikpoor.
Can you describe the impact of menopause on bladder and bowel control?
With perimenopause we start to see changes in hormone levels, mainly oestrogen. For many women, the onset of night sweats and hot flushes can be very abrupt, but bladder and bowel symptoms can develop very slowly, so this is not usually a sudden change.
Many women may also find their hot flushes and night sweats so overwhelming to deal with they may ignore other less bothersome symptoms. Once these settle down, some women will notice their bladder and bowel function is affected. Lets look at the impact of menopause on the female bladder.
The genital tract, the vagina, vulva, and surrounding area, share embryonic origin (that is when a baby is growing in the mothers womb) with the lower urinary tract, that is the urethra and part of the bladder. Oestrogen receptors are present here, so whenever you see change in the genital system you can also see changes in the lower urinary tract.
What happens for women is that they go from oestrogen abundance to significant deficiency and with that there is also a reduction in collagen and hyaluronic acid in the tissues. All these changes lead to differences in the connective tissue, which becomes thinner and loses its consistency. The term vulvovaginal atrophy was previously used to reflect these changes in the vulva and vagina during menopause.
However, in 2014, the North American Menopause Society together with the International Society for the Study of Women's Sexual Health changed this to the genitourinary syndrome of menopause (GSM) which explains much more of what is really going on.
What are the physiological reasons a menopausal woman may experience overactive bladder and/or urge incontinence?
It is common for women to experience vaginal dryness, pain, lack of sexual arousal and satisfaction and urinary symptoms such as urgency, discomfort and urge incontinence. Lets flashback to 20 or 30 years earlier when a woman gives birth.
Normally, there is some degree of trauma to the pelvic floor, but the woman was younger, her pelvic floor muscles stronger then and more responsive to pelvic floor exercises, so compensatory mechanisms kick in and she may have no further trouble.
However, when she reaches menopause, the lack of oestrogen in the pelvic floor muscles, along with the changes in connective tissue and pelvic floor muscle trauma can lead to prolapses (dropping or bulging) of the uterus, bladder and bowel, which in turn can cause incontinence. If she has urinary symptoms and vaginal dryness, she may not act on these whilst she is dealing with bigger issues such as hot flushes, night sweats and mood symptoms.
A woman's sexual function can also be affected quite significantly. Women can report sexual dysfunction from lack of lubrication and dryness. They may also report bleeding and pain with intercourse, which can last for several hours afterwards. It is not surprising that if your desire and arousal is affected, this will also affect your self-confidence and further reduce desire. Menopausal women also frequently present with urinary tract infections (UTIs) which can be debilitating.
What do you usually recommend as the first line of treatment?
I always say seek advice from the right medical professional and treatment usually involves a step-by-step approach. The starting point is lifestyle modification, encouraging people to adhere to an active and healthy lifestyle. I regularly refer my patients to the Continence Foundation website to access the guide on healthy habits for bladder and bowel.
As well as this we need to look at reducing smoking and alcohol consumption, ensure regular exercise, weight management, fluid control and dietary balance with adequate fibre. There are great resources available for free on the Australian Menopause Society Website. If this conservative approach doesn't help then its very important to see a GP with a particular interest in women's health, such as the Jean Hailes for Women's Health practitioners.
The next step may be the restoration of oestrogen receptors with supplemental vaginal oestrogen. This has good effects on the genitourinary symptoms of menopause. I also refer all women to a pelvic floor physiotherapist and in some cases a sex therapist.
So, to summarise, the first line of treatment is the conservative one, addressing diet and lifestyle factors, then potentially vaginal oestrogen, and pelvic floor physiotherapy as a long-term investment for women in this age group. Naturally, if there are more significant issues such as recurrent UTIs, the presence of a mass or tumour, or history of cancer, they may need referral to a specialist.
Why is it that some women who have had birth injuries such as anal sphincter damage don't experience bowel control problems until the onset of menopause?
Bowel control problems at menopause may be caused by pelvic floor injuries sustained at childbirth that can remain dormant. As time goes on, menopause comes along with the weakening of the pelvic floor and the connective tissue changes which may contribute to bowel control issues.
Along with all these processes, we also have ageing so our capacity to regenerate tissue and the capacity of our muscles is reduced. This is where the role of physiotherapy comes in to help strengthen the pelvic floor. If there are significant issues or no response to conservative therapy, a referral to a specialist is required.
What are some of the other common conditions you see in women who have poor bladder and/or bowel control?
Pelvic organ prolapse (POP) is not uncommon. This is where there may be a bulge or lump and a feeling of heaviness in the vagina and pelvic area. In more severe cases there may be a protrusion or lump coming out of the vagina.
If not well managed, other conditions may worsen the symptoms. These include uncontrolled diabetes, a chronic cough and chronic constipation; repeated straining can contribute to POP, hernia formation and haemorrhoids. We also need to consider the very real current pattern of obesity which plays a role in prolapse and urinary incontinence as well as putting greater pressure on the pelvic floor. There is evidence that just 10% weight loss can lead to significant improvement in urge and stress urinary incontinence.
Finally, tell me a little about yourself
I am a urogynaecologist and pelvic reconstruction surgeon. I have been with Jean Hailes since 2019 and it has been a great honour to be a part of this organisation.
I work mainly in the Clayton medical centre as their urogynaecologist and at pelvic floor and perineal clinics in Dandenong hospital. In the perineal clinic we see women who've experienced anal sphincter injury during childbirth. I work with a great team of pelvic floor physiotherapists, and I do rely on their skills. Without physios, I'm like a surgeon without arms.
How did you become interested in gynaecology and urogynaecology?
When I was a junior doctor, I had the opportunity to work with some senior obstetricians and gynaecologists. They became a true inspiration to me and set some standards in my career. In amongst the gynaecological conditions, pelvic floor problems are the ones that women may not come forth with. There is a stigma and 'suffer in silence' pattern with these symptoms. I have a keen interest in this field and would like to help women with these problems. What I would like to achieve in my career, is to inform and educate women on these matters and to let them know there is help available and you are not alone.
By Nicola Reid, Media & Content Health Writer, Continence Foundation of Australia.
Interview with Dr Payam Nikpoor, Urogynaecologist MD, FRANZCOG, CU