The Health Problem We Need to Talk About More

By Karen Tang, MD, MPH

Countless books have been written about dieting, weight loss, and preventing cancer, but there are not nearly enough books about period problems, pelvic pain, sexual health, and fertility issues. These gynecologic problems affect more than half the population, but we don’t talk about them. Why? Because they’re stigmatized and considered embarrassing, and because women’s health issues have been universally understudied and underfunded.

Despite our individual compassion and dedication [as healthcare providers], the healthcare system is failing too many of our patients. It takes most endometriosis patients seven years and visits to three or more doctors to receive a diagnosis. Imagine suffering with debilitating pain for seven years while trying to get help from doctor after doctor. I know that this isn’t because providers don’t care about their patients or are misogynistic. We want to be the best caregivers and diagnosticians that we can be.

That said, we are the products of our medical education system and training. Unfortunately, the lessons we learned originated in a patriarchal society that often got it wrong. Medical students are taught that women who complain about pain, bleeding, GI and bladder symptoms, migraines, and fatigue but who have normal ultrasounds are just anxious, not that those symptoms are classic signs of endometriosis. If doctors perpetuate these mistaken ideas, we’ve gotten it wrong, despite our best intentions.

I was motivated to write my book, It’s Not Hysteria, by countless stories I’ve heard over the years from patients in my practice, of people who have suffered enormously from a wide range of gynecologic issues: pelvic pain, menopause, abnormal periods, sexual dysfunction, infertility, and others.

Patients experiencing incontinence on a regular basis can feel extremely distressed: leaking can affect people’s ability to work or exercise and can cause odor and vulvovaginal infections. 

Fortunately, there are several treatment options to help manage the leaking so people can get back to their daily activities without having to constantly search for the nearest bathroom.

During an evaluation for urinary incontinence, a doctor will ask about symptoms, including how often leaking is occurring and how much urine comes out, what triggers the leakage, and if there are any associated issues, such as difficulty emptying the bladder or problems with sensation. It may be helpful to keep a diary noting frequency of urination and leakage, volume of liquids consumed per day, and any activities observed to cause leaking.

Doctors will perform an examination to assess for signs of prolapse and dryness associated with menopause or low estrogen and to check genital sensation and pelvic muscle strength. A urine sample may be obtained to rule out urinary infections.

There are also tests called urodynamics that a urogynecologist may perform to assess the patient’s ability to fully empty the bladder and to evaluate the pressures in the bladder and urethra. Urodynamics are sometimes used to determine the type of problem present or help the doctor decide on a course of treatment. However, some types of incontinence, such as urge incontinence, can be treated without any testing beyond a basic physical exam and a urine sample.

Treatment for urinary incontinence starts with lifestyle modifications and low-risk medications such as vaginal estrogen. Other medications, procedures, and surgeries may be used for patients who are not getting enough relief with less invasive treatments.

Small daily changes can help prevent or minimize leaking. Basic lifestyle modifications include staying away from beverages that irritate the bladder and scheduling more frequent bathroom breaks to keep the bladder less full. This can improve urinary incontinence without the side effects of medications and the risks of surgeries.

Certain drinks, such as caffeinated or carbonated beverages and alcohol, can increase urine production or increase bladder urgency, so it is recommended to restrict or limit their consumption. If someone is having nocturia, they may need to stop drinking liquids after dinner. Drinking smaller amounts of water regularly throughout the day rather than large amounts less frequently may also decrease urgency and leaking. 

Kegel exercises to strengthen the pelvic floor muscles can help prevent incontinence. To do them, imagine that you are trying to cut off the stream of urine by squeezing the vaginal muscles. The muscles must be contracted for ten seconds and then fully relaxed, and this cycle should be repeated up to ten times in a row for three sets of repetitions each day. It may take many weeks or months to see results, but studies show that if done properly, Kegel exercises can significantly improve stress incontinence. However, Kegels are difficult to perform effectively because people may not be sure which muscles to squeeze or they might not do the exercises with enough regularity to make a significant difference. For patients who have spasms of the pelvic floor muscles, doing Kegels can also actually worsen bladder control because they further strain muscles that are already tight and dysfunctional. Pelvic physical therapy helps guide pelvic floor and bladder training, and it’s an excellent option for patients who may be struggling to perform Kegel exercises or who have other problems with pelvic floor dysfunction.

There are two main categories of medication used to treat urinary incontinence: vaginal estrogen suppositories, which strengthen the tissues of the vagina, urethra, and bladder, and oral medications that relax the bladder. Botulinum toxin can also be injected into the bladder to decrease urgency.

When less invasive methods aren’t effective, there are surgical options for the treatment of incontinence. Urge incontinence can be treated with devices that use electricity to stimulate the nerves that govern bladder function, and treatments for stress incontinence include procedures that support the urethra and prevent urine from leaking through.

Leaking urine is a universal experience for nearly every woman at some point in their adult lives. Many [of us] feel relief when [we] learn that [our] experience is so common. 

To learn more about Karen Tang’s work and other common health challenges, pick up her book, It’s Not Hysteria, Everything You Need To Know About Your Reproductive Health (But Were Never Told).

EXCERPTED FROM IT’S NOT HYSTERIA. COPYRIGHT © 2024 BY KAREN TANG. EXCERPTED BY PERMISSION OF FLATIRON BOOKS, A DIVISION OF MACMILLAN PUBLISHERS. NO PART OF THIS EXCERPT MAY BE REPRODUCED OR REPRINTED WITHOUT PERMISSION IN WRITING FROM THE PUBLISHER.