Dr. Barbara Bartlik is a recognized expert in integrative psychiatry with a focus on women’s health and sexual wellness. Triple board-certified in psychiatry, integrative medicine, and sexology, Dr. Bartlik brings over 30 years of experience treating patients with various health concerns, including pelvic floor disorders and sexual health issues. A popular speaker at this year’s RENEWAL SUMMIT, the following interview questions further explore her expertise on incontinence treatments and pelvic health, a condition of concern to nearly half of women over 50.

UNDERSTANDING INCONTINENCE AFTER MENOPAUSE

With a significant number of women experiencing urinary incontinence, it’s crucial to understand the different types of incontinence (stress, urge, mixed) and how this condition changes with age. Early intervention is not just key; it is a proactive step towards better health. So, what prevents women from seeking help? 

Stress incontinence is urinary leakage in response to actions that put pressure on the bladder, such as sneezing. Urge incontinence is the sudden urge to urinate and subsequent leakage. Mixed incontinence occurs when someone experiences both types of urinary incontinence. Most women delay seeking help for this problem, which is unfortunate because the earlier it is addressed, the better.

Statistics indicate that women wait an average of 6.5 years before seeking a diagnosis for bladder control problems. What are the consequences of a delay in treatment, and how does incontinence affect women’s daily activities, social interactions, and quality of life? 

Bladder control problems are related to pelvic floor muscle weakness and dysfunction. Sometimes, this can lead to prolapse or lowering of the pelvic organs (bladder, uterus, rectum, or vagina) into the vagina or rectum. Pelvic floor physical therapy, an effective treatment, is often overlooked by many women and their healthcare providers. Women may be busy with the demands of home and work or may not comprehend the seriousness of neglecting this part of their body. Also, they may be afraid of the possibility of undergoing surgery. This delay can lead to a worsening of the condition, increased social isolation, and reduced quality of life. Many women live with incontinence for many years and cope by curtailing their activities and travel and by wearing pads and adult diapers. Sexual problems such as decreased sensation, difficulty achieving orgasm, and vaginal pain or discomfort may also occur with pelvic floor dysfunction.

MENOPAUSAL AND HORMONAL CHANGES AFFECTING PELVIC HEALTH

How does the decrease in estrogen during menopause affect pelvic floor muscles, and can you explain the connection between vaginal atrophy, decreased tissue elasticity, and incontinence symptoms? 

 When we think of estrogen and its effect on a woman’s body, we generally think of the way it affects the vaginal tissues by making them stronger, thicker, more resilient, and better lubricated. However, the effect estrogen has on the muscles of the pelvic floor is equally important. The low estrogen levels of menopause make the pelvic floor muscles less elastic and less able to support the bladder, uterus, and rectum, so prolapse and incontinence are more likely to result.

Beyond estrogen, what other hormonal changes during and after menopause impact pelvic floor health? Separate from hormonal factors, what structural and functional changes occur in the pelvic floor as women age?

DHEA, testosterone, progesterone, and thyroid hormone also decrease with menopause. DHEA is a precursor to estrogen and testosterone, and when levels are low, it affects energy, muscles, mood, cognition, and vaginal health. Testosterone deficiency has similar effects. Low progesterone can cause insomnia, anxiety, and estrogen dominance. Menopause increases the risk of hypothyroidism, so thyroid hormone should be monitored.

Eighty percent of women who develop incontinence are mothers, so the pressure of pregnancy and vaginal delivery appears to contribute to pelvic floor weakness. Some women today choose elective Cesarian sections to preserve their pelvic floor. Obesity and excessive sitting, especially with poor posture, put pressure on the pelvic floor. As we age, we lose muscle throughout our bodies. Increasing abdominal pressure from straining due to constipation and pressure from chronic coughing can also weaken the pelvic floor, along with other factors.

CONVENTIONAL TREATMENT APPROACHES

Pelvic floor muscle exercises (Kegels) are often recommended, but studies show only 38% of women perform them. What makes these exercises effective, and why don’t more women practice them?

 Kegel exercises, which involve contracting and relaxing the pelvic floor muscles, are effective in managing incontinence. They can be done anywhere, at any time, and are a key component of pelvic floor physical therapy. While they may be challenging at first, with practice and patience, many women find them effective in strengthening their pelvic floor.

Many women do not perform Kegel exercises as often as they should, or they do them incorrectly. They may ignore the problem until it is too late. Kegels are time-consuming, require attention, and the results take time to achieve. Some women push down instead of pulling up. They also do not breathe properly. It is essential to exhale during the exertion phase of the exercise (when pulling up) and inhale during the relaxation portion (when letting go). This proper breathing technique is crucial for maintaining the integrity of the pelvic floor, and it is a key piece of information that many women may not be aware of.

What are the most effective behavioral modifications (like fluid management, scheduled voiding, etc)  recommended for women with incontinence?

Although restricting fluid intake seems logical, it is not a good long-term solution. You need to stay well-hydrated to avoid urinary infections and other health problems. Drink at least half your body weight in ounces per day (a 140 lb person should drink at least 70 oz a day). Spread your intake out throughout the day and avoid excessive intake at bedtime. If you cannot cut out caffeine, limit intake to 8 ounces a day.

Scheduling voiding: If you need to pee every 30 minutes, try to wait until an hour has passed before your next trip to the bathroom. Continue to increase over time, with the goal being 3-4 hours between each bathroom trip.

What medications are available for different types of bladder control, and how effective are they? 

Medications used to treat incontinence include anticholinergics, also known as antimuscarinics, which can cause side effects such as dry mouth, constipation, blurred vision, lethargy, and increased eye pressure. The antidepressant duloxetine is sometimes recommended. It may increase the muscle tone of the urethra, but it can cause nausea and side effects similar to those of anticholinergics. Other medications used for bladder control include beta-3-receptor agonists, such as mirabegron. They relax the muscles around the bladder but can cause side effects of nausea, diarrhea, constipation, and headache. To reduce nighttime urination and get a good night’s sleep, you can take desmopressin, which reduces the amount of urine produced at night. Loop diuretics are also an option, but they are not approved for this purpose. When considering these medications, you must weigh the risks and benefits, consult your physician, and make an informed decision for yourself.

When do you recommend vaginal estrogen therapy? What are the different delivery methods, and how quickly can patients expect to see results? Moreover, what are any risks associated with long-term usage? 

 Vaginal estrogen creams are very effective in rejuvenating vaginal tissues and treating vaginal atrophy due to menopause. They thicken and strengthen the cells lining the vagina and urethra and reduce vaginal discomfort, pain during intercourse, itching, and the frequency of urinary and vaginal infections. Estrogen can be delivered vaginally in many forms: a cream inserted into the vagina with an applicator or spread on vaginal and labial tissues, a ring that fits around the cervix, or a suppository. It may take 2-4 weeks for vaginal moisture to return, 4-6 weeks for relief of pain on intercourse, and 3 months for maximal effect. Vaginal estrogen increases systemic estrogen levels very little so it may be safe in some women with a history of hormonally sensitive cancers. Nonetheless, there is no guarantee, and each woman should research the issue and consult her doctor for personalized guidance. It may be necessary to obtain annual vaginal ultrasound scans to monitor the endometrium for signs of cancer when taking vaginal and other forms of estrogen.

INNOVATIVE TECHNOLOGIES

What innovative technologies do you consider promising for treating incontinence, how do they work, and what advancements have you seen in these areas? 

High-intensity focused electromagnetic technology is used to strengthen and tone the pelvic floor muscles. It improves urinary incontinence, pelvic organ prolapse, and vaginal laxity in women and sexual function in men and women. Electromagnetic pulses stimulate the pelvic floor muscles as the individual sits in a chair, causing the muscles to contract repeatedly. One example is the Emsella© Chair. Typically, six treatments are administered over a period of two weeks. Emsella uses a form of Pulsed Electromagnetic Frequency (PEMF). PEMF increases nitric oxide production in the endothelial cells that line the blood vessels, causing them to relax and dilate. PEMF improves circulation and oxygenation, reduces blood pressure, promotes healing, and increases genital engorgement. Studies show that nitric oxide levels in plasma increase after PEMF application. PEMF stimulates cell growth and repair; may improve vulvovaginal atrophy, erectile disorder, and orgasmic difficulties; and helps neurogenic overactive bladder and mixed incontinence (stress and urge).

Radiofrequency Thermal Treatment is usually performed by gynecologists and involves inserting a probe in the vagina that delivers painless heat to the vaginal canal and external clitoral and labial tissues. The claim is that it improves circulation and blood flow, stimulates the production of new collagen, and regenerates nerves. Women have reported improvements in postpartum healing, ability to orgasm, sexual pleasure, vaginal intercourse satisfaction, vaginal laxity, vaginal moisture during sexual activity, mild bladder prolapse, and urinary leakage, but more research is needed to prove these benefits. Three treatments, spaced a month apart, are usually recommended.

Neuromuscular Electrical Stimulation devices deliver electrical current to the pelvic floor, causing the muscles to contract rhythmically without conscious effort. The electrodes can be applied externally to the vulva via tight-fitting shorts and adhesive leads or intravaginally through a probe. These devices are used in pelvic floor physical therapy and are available for purchase and use at home.

INTEGRATIVE MEDICINE APPROACHES

 As an integrative medicine specialist, how do you approach incontinence differently than conventional practitioners, and what complementary therapies have you found effective when combined with standard medical treatments?

I recommend cranberry-mannose supplements, which can reduce the frequency of urination by fighting bacteria in the bladder. Nicotine and foods and drinks that irritate the bladder should be avoided, including coffee, tea, spicy foods, carbonated beverages, chocolate, citrus fruits, and alcohol. The amino acids taurine, L-theanine, glycine, and L-arginine may help reduce nighttime urinary frequency; however, this research is preliminary. Several technologies and muscle-building nutritional supplements are mentioned in this article that I recommend.

What dietary or nutritional approaches have you found helpful in improving pelvic floor health, and do you find a connection between pelvic health and gut health? 

The pelvic floor and gut health have a significant impact on one another in numerous ways. A pelvic floor that is too weak or too tight can cause constipation. Straining to pass stools can lead to pelvic floor muscle weakness and prolapse. Pelvic floor dysfunction can cause a feeling of not completely emptying the bowels. Gut inflammation and dysbiosis can cause gas, bloating, and frequent bowel movements, which can stress the pelvic floor and lead to discomfort. An unhealthy gut causes inflammation, which can worsen pelvic pain conditions. A healthy diet that minimizes gluten, dairy, alcohol, toxins, and sugar and includes probiotics and digestive enzymes promotes healthy gut flora and reduces inflammation.

Are there specific supplements or natural compounds you recommend to support pelvic floor function? 

Ensure you get enough protein, which contains muscle-building amino acids. Take amino acid supplements and beta-hydroxy-beta-methylbutyrate (HMB), which has been shown to enhance protein synthesis and preserve muscle.

 PREVENTATIVE STRATEGIES

Lastly, what preventive methods can you recommend for women in their 40s to protect their pelvic health as they approach menopause? Beyond Kegel exercises, what physical activity or movement exercises best support long-term pelvic floor health?

Many exercises strengthen the pelvic floor, including some yoga poses and pilates moves. The pelvic brace, pelvic tilt, bridges with knee taps, deep squats, lateral lunges, inner thigh squeeze, clamshell, prone diamond (), and diaphragmatic breathing are all helpful. It is also beneficial to use a standing desk to minimize excessive sitting. If you have sinus or lung problems that cause frequent throat clearing or coughing, address them early to prevent pelvic floor weakness. Address constipation to avoid straining during bowel movements. Lastly, maintaining a normal weight can help reduce pressure on the pelvic floor.

Barbara Bartlik, M.D. is an expert in integrative psychiatry, emphasizing evidence-based holistic approaches to mental health and sexual wellness. She is skilled in addressing conditions such as depression, anxiety, post-traumatic stress disorder, women’s health issues, and sexual dysfunctions. She has been in private practice in Manhattan for over 30 years and combines conventional psychiatric treatment with lifestyle interventions, nutritional strategies, genetics, detoxification, and novel neurostimulation modalities. Dr. Bartlik is triple board-certified in psychiatry, integrative medicine, and sexology. She is a locally, nationally, and internationally sought-after speaker and a featured guest on talk shows and podcasts. She is the editor of Integrative Sexual Health and is recognized among New York Magazine’s Best Doctors in Psychiatry. Visit her website.

Medical Disclaimer: The information provided in this article is for educational and informational purposes only and is not intended as medical advice.  Always consult your healthcare provider for personalized medical guidance.