Choosing the right treatment for pelvic organ prolapse

Pelvic organ prolapse is a common condition that ranges from having no symptoms or just mild irritation to having a significant effect on a women’s quality of life. If you are experiencing symptoms associated with prolapse, there are many options available to suit your situation, says Oxford Women’s Health urogynaecologist Dr Fiona Bach. For some, that may include doing nothing, pelvic floor physiotherapy, vaginal pessary, or surgery, which can all be discussed with your General Practitioner.

What is a prolapse?
Pelvic organ prolapse occurs when the collection of muscles and ligaments that hold up our pelvic organs weaken, causing one or more organs to move from their usual position down into the vagina. Up to 40 per cent of women who have had children will experience some form of prolapse in their lifetime. It can occur as a cystocele (when the bladder moves down into the vagina); rectocele (involving the bowel); uterine (involving the uterus and cervix), or vaginal vault (affecting the area at the top of the vagina after hysterectomy). People often describe the feeling of a vaginal bulge, pressure, heaviness and a dragging sensation. They may also experience discomfort during sex and/or a lack of sensation or a feeling of openness in the vagina. Bladder symptoms associated with a prolapse include a weak or prolonged urine stream, incomplete bladder emptying that can lead to recurrent Urinary Tract Infections (UTIs), urgency, increased frequency and incontinence. Bowel symptoms include finding it difficult to open the bowels and even needing to press the bulge back in to open the bowels. If you are experiencing these symptoms, it’s important to see your General Practitioner.

Ways to manage prolapse
In the early stages, prolapse can often be improved with physiotherapy and pelvic floor exercises. Another option is using a pessary, a small silicone or plastic device that is placed in the vagina to provide support. They come in many different shapes and sizes, and while it sometimes takes a bit of trial 
 

Dr Fiona Bach

and error to find the one that suits you best, your GP will be able to support you with that. 

When surgery is required
Surgery is very common with up to 20 per cent of women needing an operation to repair a prolapse at some point in their lives. There are several options available for vaginal prolapse depending on what needs to be repaired. A cystocele repair or anterior repair is performed vaginally and works by pushing the bladder back to its original position and using some strong stitches to keep it there. It generally only requires a one-night stay in hospital. A similar procedure is used in a rectocele repair or posterior repair, where the bowel is pushed back to its original position. Options for treating a uterine prolapse include a vaginal hysterectomy or sacrospinous hysteropexy where the uterus is lifted up and stitched to a strong ligament high in the pelvis. Vaginal mesh is no longer used in New Zealand.

Abdominal procedures include a sacrohysteropexy or sacrocolpopexy, which use a mesh to lift the prolapse up and suspend it from a bone in the spine. This involves using a lightweight mesh, which is different from older types of mesh, and it does not go through the vaginal skin, which is what caused past mesh problems you may have heard about.

The best course of action is to discuss all options and risks with your specialist who will be able to provide you with some excellent patient decision aids to help you work out which option suits you best.

Navigating nutrition and perimenopause

During perimenopause, many women start to notice changes to their body that suddenly don’t make sense. This may include the onset of digestion problems, higher cholesterol readings, disrupted sleep, and aching joints. So, what’s causing these changes and what can we do about them? In this article, Oxford Women’s Health Dietitian Sara Widdowson, explains how nutrition can help make perimenopause more manageable.

Everyone’s experience of perimenopause will be slightly different, with many women noticing symptoms such as weight gain and sleep disruption. These changes happen because during perimenopause - the transitional time before menopause – our essential sex hormone levels begin to drop, particularly estrogen and testosterone. This can cause hormonal and metabolic changes as well as insulin resistance, which increases our blood sugar levels.

A common reason people come to me for support is because they feel that their weight gain has become out of their control. Sometimes people will turn to very low-calorie diets as a result, but this will only exacerbate symptoms. Among the reasons for weight gain during perimenopause is estrogen’s involvement in the regulation of how our body stores and uses fuel. Declining muscle mass also contributes to a lower metabolism. Disrupted sleep can worsen insulin resistance and is associated with a higher production of some appetite or hunger hormones, such as ghrelin. We also know that the loss of the protective effect of estrogen increases the risk of heart disease in women, and we are learning more about the impact fluctuating sex hormones could have on gut health. Changes to progesterone levels can cause bloating and influence the time it takes for food to pass through the gastrointestinal tract. As estrogen declines, our gut microbiome diversity can also be reduced, increasing food sensitivities. So, what can we do to support our bodies with nutrition during perimenopause to help make this transition more manageable?

Increase protein
Do you ever find yourself nibbling away at the vegetables on the chopping board as you prepare them for dinner? This is called ‘rebound nutrition’. It happens when people don’t eat enough until 3pm and then when they come home from work, they unconsciously snack on food before and after dinner. To overcome this, I encourage my clients to frontload their day with protein. Prioritising protein is important in managing increased insulin resistance during perimenopause because it reduces the glycaemic load of carbohydrate meals. By including protein with carbohydrates, the insulin response is reduced, gut transit time slows, and we feel fuller for longer. Perimenopausal women need 1.5-2g of protein per kilo of body weight, per day. This needs to be higher for women doing resistance training. Good sources of protein include poultry, eggs, dairy products, tofu, and tinned fish. A chicken thigh has about 22g of protein, half a cup of high protein yogurt provides 14g, and an egg has 8g of protein. Other good protein options include bovine collagen supplements, grains such as millet, oats, brown rice, and some vegetables, such as protein-dense peas and edamame beans.

Be carbohydrate aware
People are often surprised to find out about the carbohydrate density of foods, but there are plenty of easy swaps that can help make a big difference, for example swapping a standard supermarket bought wrap for a lower carb one. Carbs can also be hidden in a variety of foods. For example, a lot of the plant-based milks on the market are low in protein but come with a high carbohydrate count.
A good swap would be choosing a high protein almond milk, a glass of which has 10g of protein, versus a standard glass of almond milk which has 0.8g of protein. People are often surprised to learn that four to five bliss balls provide the same amount of carbohydrates as a sandwich, so while they’re great during exercise, they are not the best choice for an afternoon snack in the office.

Boost fibre
Fibre is important for cholesterol management, gut microbiome health, and keeps us fuller for longer. It can 

Sara Widdowson

also assist with reducing the glycaemic load and that insulin spike after a meal. Adding fibre and fat, in the form of nuts, seeds, avocado, and olive oil, is important for glycaemic load management. If you also add acidic foods, like balsamic dressings, pickles, apple cider vinegar, and lemon juice, it can further reduce the glycaemic load. We should aim for 25-30 grams of fibre per day. People are surprised to learn the number of foods you need to eat to hit that fibre target, for example one cup of garden salad has 3g of fibre, versus one tablespoon of chia seeds with 6g. Tiny changes to our diets can really help.

Cardiovascular disease risk and nutrition
The loss of the protective effect of estrogen increases the risk of heart disease for women. It is thought estrogen mediates cholesterol response and production in the liver, plays a role in the elasticity of blood vessels, and reduces oxidative stress and inflammation. When estrogen declines, women can also experience changes to their blood pressure. Ways to support better heart health, include managing insulin resistance, reducing alcohol intake, increasing fibre, and wherever possible, replacing saturated and trans fats with mono and polyunsaturated fats - the plant-based fats. Instead of using butter, opt for avocado, add nuts and seeds, and include good fish sources in your diet, such as mackerel, sardines, and salmon.

It’s also important to take stock of how much alcohol you are drinking as we know it is a risk factor for heart disease and breast cancer. Women often use alcohol as a stress release or an end-of-day ritual, but we know that it impacts on sleep quality in a similar way to caffeine. It’s also thought to change our brain’s ability to access some of our neurotransmitters like dopamine and serotonin, which is so important in times of anxiety or stress.

Bone health
Declining estrogen is also associated with changes in bone health. Women over 50 require between 1000 and 1200 milligrams of calcium each day, which is easily achieved by including three daily serves of dairy products. People at an increased risk of calcium inadequacy are those who are lactose free, have a lactase deficiency, are vegan or choose to be plant-based, and those with poor eating habits. For these groups of people, I recommend including foods like tofu, which is a great source of calcium, and if you use plant-based milks, always remember to give them a shake as the solidification at the bottom of the plant-based milk is the calcium fortification. Correcting Vitamin D deficiencies can improve calcium absorption, so play an important role in bone health. Dietary calcium is preferred as it absorbs better, but when it comes to Vitamin D, a seasonal supplement is recommended.

Gut health
During your period years you may have noticed your digestion changed at different times during your menstrual cycle. Due to a change in gut microbiome diversity during perimenopause, those symptoms can become heightened, and women may experience increased food sensitivities. Always be aware of any red flag symptoms and talk with your GP. The vaginal microbiome is also influenced by hormone changes and women may notice vaginal dryness, bacterial yeast infections, Urinary Tract Infections, and Genitourinary Syndrome of Menopause (GSM) symptoms. Ways to support digestion during perimenopause include identifying common triggers, chewing food well, sitting down to a meal, managing stress and anxiety, and incorporating probiotic-rich functional foods like sauerkraut, and kimchi into our diets. Probiotic supplements may also be an option.
 

Celebrating International Women's Day

A presentation by one of Oxford Women’s Health’s physiotherapists was one of the highlights of The Breeze Canterbury’s International Women’s Day event on 7 March.

Held at The Loft Bar, guest speakers included Oxford Women's Health Pelvic Health and Musculoskeletal Physiotherapist Niamh Clerkin, Joy Reid from One Mother to Another, Hannah Romano, and The Breeze announcer, Sarah Van der Kley. 

General Manager Catherine France said she was delighted to be a part of the 

event and see so many people come along to listen to such inspirational women.
 

Canine trial receives exciting boost

K9 Medical Detection New Zealand’s (K9MD) groundbreaking clinical trial received a remarkable boost in March, thanks to the Royal Canin Foundation.

K9MD is a Dunedin-based Charitable Trust that uses specially trained dogs
to assist in the detection of cancer and other diseases in a controlled clinical environment. Oxford Women's Health is proud to be working with K9MD on
a clinical trial that researches the early non-invasive diagnostic testing of ovarian cancer. It is hoped that in the future the dogs could be used as an additional diagnostic tool to save lives.

A grant of $183,000 from the Royal Canin Foundation means K9MD can recruit more nurses across the country to collect a wider range of urine samples for the dogs' training; and contribute to K9MD’s specialist trainers 

and the medical and research team.
The testing is possible because many diseases and disease-causing agents give off odours, known as volatiles.

A dog’s sense of smell is so sensitive, it can detect a teaspoon of sugar in two Olympic-sized swimming pools of water. Using medical detection dogs to identify volatile organic compounds (VOC) released from tumours could become an alternative to molecular and physical screening techniques.

To view the Seven Sharp interview with the K9MD team, click HERE.