Uterine Prolapse: What You Need To Know
By midlife, as we can all attest, our bodies have accumulated some wear and tear. For me it is my knees, for others it is their back, and for some it is their female bits and pieces.
I am fortunate to have a brother-in-law who is a professor in OBGYN at UMass Medical school. He is a fountain of knowledge about women’s health issues, and I asked him about good topics for this newsletter. His specialty being Urogynecology he suggested I write about uterine prolapse and incontinence. And being the overly modest guy he is, rather than be interviewed himself, he suggested I interview his fantastic colleague, Dr. Tanaz Ferzandi at USC Medical School.
Dr. Ferzandi is the Service Line Chief of Obstetrics & Gynecology at Keck Hospital, the Director of the Division of Urogynecology and Pelvic Reconstructive Surgery, Associate Professor of Obstetrics and Gynecology, and the Associate Fellowship Director for Urogynecology at USC Keck School of Medicine.
Both uterine prolapse and incontinence are topics people don’t like to discuss but Dr. Ferzandi is working to change this, and I believe the more informed we are about our bodies the better. So, in today’s issue we will be discussing uterine prolapse and in next week’s issue we will be covering incontinence.
What is Uterine Prolapse?
“Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken and no longer provide enough support for the uterus. As a result, the uterus slips down into or protrudes out of the vagina.” And according to Johns Hopkins University, “Nearly one-half of all women between ages 50 and 79 have some degree of uterine or vaginal vault prolapse, or some other form of pelvic organ prolapse.”
KF: What are the main risk factors for developing uterine prolapse?
Dr. Ferzandi: We think uterine prolapse is multifactorial, meaning there may be many different components involved in those who develop it. Uterine prolapse historically has been thought of as the “old lady” syndrome. And until a few years ago the typical profile was a woman who had multiple births (7, 8, 9 babies), whose tissues were less strong due to age, and who might have had a forceps delivery (a very typical form of delivery years ago).
But we are now seeing prolapse in younger and younger women. Women who have only had 2 or 3, maybe 4 children.
I believe one factor contributing to this change is women are having larger babies. In the past women didn’t have 8, 9, 10, 11-pound babies.
In addition to larger babies, women are now pushing longer during their deliveries. In the past, after about 3 hours of pushing we would have used a vacuum or C-section to deliver the baby. Now it is not uncommon for women to push for more than 3 hours or stay in the ‘active’ phase of labor for 4-6 hours. Pushing out a 9-pound baby over 3 to 6 hours is most likely going to cause some damage.
The pelvic floor is a group of muscles holding everything in place. So, anything which puts additional pressure on these muscles can increase your risk for pelvic floor issues. Additional factors include obesity, chronic constipation (particularly for rectal prolapse) and coughing, family history and genetics (even if you don’t have other risk factors), as well as lifting heavy objects.
Aging is another factor as our tissues become less strong, particularly after age 65. Lastly, we are starting to think high impact sports and activities (like Crossfit) which involve lifting very heavy weights may make a woman more susceptible to uterine prolapse.
If these trends continue, I think we are going to see the incidence of prolapse increase in younger age groups.
KF: How do you know if you have uterine prolapse?
Dr. Ferzandi: Well, it depends on the severity, but the most reported symptom in patients of normal weight is the feeling of a bulge. But someone with advanced prolapse will know as tissue will be protruding from their vagina. Prolapse can also be detected by a routine gynecological exam.
With advanced prolapse, a woman might have to push the tissue back inside her vagina to have intercourse or to be able to completely empty her bladder. She may even have to push down mechanically inside the vagina with her finger to stimulate the stool to come out. This is because as everything bulges into the vagina it can cause the stool to get pocketed.
KF: How do you address uterine prolapse?
Dr. Ferzandi: There are essentially 3 options: do nothing, insert a pessary, or have surgery.
For minor prolapse, if it's internal and something that was incidentally picked up during a pap smear, I can take measurements. Once I have assured myself and the patient there is nothing of immediate concern, I ask them if it is bothering them? If it is not bothering them then we can monitor the situation and measure as part of their yearly exam. If it changes dramatically on subsequent visits, we can pursue other options.
If tissue is coming out of the vagina, I tend to be more aggressive in intervening because the tissues can get dry and/or damaged. In these cases, we sometimes use a device called a pessary.
Pessaries have been around for ages. They are silicone devices which come in all shapes and sizes. They are inserted in the vagina to push everything back into the vagina. The type inserted depends on the extent of the prolapse and the needs of the patient. Does the patient plan to be sexually active? Will they be removing it themselves?
A lot of my older patients feel comfortable with the idea of pessary because they used a diaphragm in the past. My younger patients sometimes do not like the idea of walking around with a device in their vagina.
If a woman requires surgery, there are a lot of options depending on which of the vaginal compartments is impacted. Treatments can be local and done vaginally or may require a more complex surgery. The gold standard of prolapse repair is a procedure called a sacrocolpopexy. It can be performed via many routes (laparoscopically, robotic-assisted, open incision) and has been around for decades.
A general gynecologist can do simple prolapse procedures. But for advanced prolapse I suggest women see someone who is fellowship trained because they will have more treatment options to offer and are trained to manage any complications that might occur.
KF: Are there ways to prevent uterine prolapse?
Dr. Ferzandi: Yes, there are steps women can take to strengthen their pelvic floor including focusing on straight posture and pelvic floor training (including “Kegels”). These exercises do help and can be preventative but are not curative of existing prolapse.
However, a lot of women do not do Kegels correctly. They tend to bear down and end up compressing their abdominal muscles rather than activating the levator muscles. I would say 50% of the time when I'm doing a gynecologic exam on a patient, and I ask her to demonstrate a Kegel exercise she is not using the right muscles. And sometimes even if the woman is recruiting the correct muscles, I only feel a flicker of muscle strength contraction.
I have seen pelvic floor therapy be beneficial for women with minor pelvic floor issues and eliminate the need for other medical intervention. Physical therapists can use biofeedback to help ensure the right muscles are being recruited and strengthened.
Sometimes this type of PT is not covered by insurance but it is becoming more accessible as payors recognize the utility of physical therapy. The type of training and experience of the therapists is also varied, so it’s crucial to get the referral from your urogynecology specialist.
KF: Any last thoughts?
Dr. Ferzandi: Women are notorious for not taking care of themselves as they take on so many caretaker roles. The saddest thing about prolapse is how long some women will live with it before going to see their doctor. They can think, “Well it is not killing me.” “I’m not dying of cancer.” “I can live with this.” But you don’t have to! I would encourage women to not be embarrassed to discuss this topic with your doctor as many women have this condition.
Parting Thought
I love that doctors like Dr. Ferzandi are working to destigmatize women’s health issues. It enables us to better take control of our health and how we show up in the world.
See you next week…
