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Dr. Jones: Today, in The Scope studio, we're talking with Dr. Audra Jo Hill. Dr. Hill is a urogynecologist, who specializes in problems with the pelvic floor, the down there that isn't always the same after childbirth. She started a new clinic for postpartum pelvic floor problems. Welcome to The Scope, Dr. Hill. So help us understand a little about this specialty clinic. What made you decide to start this clinic?

Dr. Hill: I think I was going through training and treating patients, I started to recognize unvalidated problem, an unspoken problem that a lot of women experience following childbirth. There's small specialty clinics across the country that really focus on postpartum pelvic floor disorders, but we didn't have anything here in the state of Utah, and helping fix some other problems following deliveries has really motivated me to start the clinic. I find ways to help these women who previously had gone untreated.

Dr. Jones: And they've come to you. They probably came to you even before you formally started this clinic. Is there a story? Is there . . . Not without using anybody's name, but someone who's come, who's had a baby, is overwhelmed, and she can't talk about the fact that either it hurts or she leaks or . . . And it's kind of overwhelming. She's just trying to be a happy mom, but she's not so happy. Is there something that's common?

Dr. Hill: Yes. So following delivery, some women can experience different levels of vaginal tears that can occur. And one story that really sticks out in my mind was a woman who sustained a fourth-degree laceration.

Dr. Jones: That's where the tear went all the way through the muscles around the rectum and into the rectum.

Dr. Hill: Correct. And she was repaired appropriately at the time of her delivery. But about one week later, she called in complaining of increased pain and symptoms of discharge and starting to leak stool through her vagina. And so she presented to my clinic as a new time mom, trying to handle breastfeeding, juggling life, new baby, lack of sleep, but also these problems that were not exactly on her list of following delivery.

Dr. Jones: No.

Dr. Hill: And so we were successfully able to, based on her tissue quality and her examination, to take her back to the operating room on Christmas Eve, and we repaired her vaginal tissues and her rectal tissue so that she was able to be continent. And she now is successfully able to ride her horses, and take care of her baby, and is very pleased that she doesn't have to deal with this as part of her postpartum adventures in motherhood.

Dr. Jones: Wow. You gave her a new year, a brand-new year. We've heard all over the world about the trauma of childbirth that goes untreated. We hear about women with fistulas and leaking urine all their life in Africa or in Bangladesh. But we don't really think about this happening here. And because, of course, we take care of that stuff here, or it doesn't happen here. But it does happen here.

Dr. Hill: Definitely, I think with our more differences is that we have more modern medicine, opportunities to intervene in the vaginal birth process, but the same trauma still occurs. And so women can have, you know, urinary leakage, prolapse or a vaginal bulge after delivery, fecal leakage. And just, you know, those muscles and nerves have had a lot of trauma. And how to help new moms even just understand what happened is a huge part that I think can be very reassuring.

Dr. Jones: Right. It isn't something you usually share with your girlfriends, right?

Dr. Hill: No, this is one of those things that once you start talking about it, it's amazing how many people say, "Oh, yeah, me too. I've experienced that." But it doesn't come up. And, you know, everybody wants to know how their baby is doing after delivery.

Dr. Jones: Right. Well, everybody would share their labor story, how long it was, their pain. They'll talk about how hard they pushed. They'll talk about their breastfeeding problems. But when it comes to down there, they don't talk about it.

Dr. Hill: No. And some people feel it's their price they have to pay for having children, and it's a common thing, and they just have to live with it.

Dr. Jones: Well, you mentioned, as we were talking before we got started, that the resident that was in clinic with you said there are a lot of tears in your clinic. So talk to me about that, about, you know, women who are . . . they're hormonal, they've had a new baby, they just are overwhelmed. Talk about the tears around this difficult issue.

Dr. Hill: As you were saying, it's not necessarily tears of . . .

Dr. Jones: Despair.

Dr. Hill: Yeah. Despair or fear. I think it's a validation and acceptance to tell them this is what happened to you, educating them on their pelvic floor, what this means for future childbearing. Does this change any of their options? Also looking at that telling them, "You're not broken. You're not damaged. You're just different because a baby's been there. And that doesn't mean that this is something that means you're abnormal. You're just differently from your prior normal."

Dr. Jones: That's a lovely way to put it because I always think of a vaginal birth as being a moderately traumatic process from an evolutionary perspective, but I think you've a much healthier way of bringing this process of getting a baby out. That's a good way to put it. Well, can a woman who has these problems call your clinic directly, or do they need a referral from their OB or midwife or a family physician?

Dr. Hill: So I think, though, how we're starting to work on this and, again, there's many bugs as you start to start a clinic is to give our offices a call. And we are currently looking through them to make sure (a) it's one, the appropriate provider for you. Because, again, if it's been three or four years after the delivery, there may be somebody better suited to help treat some of your symptoms. But for right now, it doesn't require referrals because I do not want to hinder patients being able to come in and see us. But primarily, always going back to your delivery and provider addressing these symptoms and concerns and asking, is there anything else that can be done is very helpful because you may not need to come to a specialty clinic. And a lot of these things can be taken care of with your own provider. But if things aren't improving, if there's complications, we are always here to help.

Dr. Jones: Right. There are a lot of women who have either bladder leakage or not being able to empty or your bladder is just not the same, and luckily, sometimes time can help. If women . . . I think women in Idaho who may be far from their own OB and farther from you, but if their own OB can help them understand that things get better. Or they could always call you and say, "This is what I got, you know. What could we do from here?" And sometimes time and things tighten back up a little bit.

Dr. Hill: You are absolutely correct. I think those first six months following a vaginal delivery, there's so much remodeling of the muscles and the tissues, and fluid shifts in the body. And if you're breastfeeding or not, the hormonal status, lots of things can change. And majority of the symptoms actually get better and go away. But I think if they're not getting better, and if you are really bothered and your quality of life is suffering, talk to your provider.

Dr. Jones: Right. Exactly.

Dr. Jones: The normal vaginal birth of a baby can be a joyful time, but most women will say that nothing is ever the same down there.

Humans are not the only species that can have trouble getting their babies out, but we seem to have the most trouble. Our babies' heads have evolved to get bigger and bigger, and good nutrition have made babies get bigger and bigger. And the baby has to pass by muscles and tissue and bowel and bladder on the way out, and often there are long-term consequences.

Today in The Scope studio we're talking with Dr. Audra Jo Hill. Dr. Hill is a urogynecologist, a gynecologist who specializes in problems with the pelvic floor, the "down there" that isn't always the same after childbirth. Welcome to The Scope, Dr. Hill.

So what are the reasons that those happen? How come women who, having just vaginal birth . . . we populated the planet with vaginal births, even though people think C-section is the most common. In fact, it's not. But what are kinds of things that happened during a birth that can lead to these kinds of problems?

Dr. Hill: So some of the risk factors that we've identified have to do with having a larger baby, sometimes an older mom and just how their tissues are different than younger moms, also genetics.

Dr. Jones: Not so stretchy or tear . . . I mean, I'm way too past older mom. I mean, what do you mean by older mom?

Dr. Hill: I think after the age of 35, just the complications of pregnancy in general, albeit still small, do increase. I think more medical comorbidities also increase. And I would say that the recovery of the tissues after the normal birthing event sometimes is slower.

Dr. Jones: Right. Well, we were engineered to get to 35, to get one generation of children to childbearing age. And so we're over-engineered, but everything starts to . . . You know, our eyes, our bones, our everything tends to be a little less resilient after 35. Oh, dear. Okay, well, I'm way after that, but that's . . . Well, let's go back to babies being bigger and mom's tissues maybe not so stretchy. What other kinds of things can make these problems happen?

Dr. Hill: We find an increased risk of these complications or disorders, such as prolapse, incontinence, or higher-level tears are associated with operative deliveries, which kind of means if we used forceps or a vacuum versus just a spontaneous vaginal delivery.

Dr. Jones: Okay. So if the baby needed some help coming out, and the obstetrician, or midwife, or family doc used something to help the baby through, that usually means that the baby was bigger anyway. So we don't know. They might have torn even if you didn't put those things on.

Dr. Hill: Correct.

Dr. Jones: It's just those things just help out. I don't want people to say, "Oh, I'm never going to have any equipment to help my baby out." Okay, that would be one too.

And then we stopped doing episiotomies routinely. That used to be pretty much commonplace, meaning to cut the opening so it got a little bit bigger. Our fear back not that long ago was, "If it tore, it would tear irregularly. If we just cut it, it would be easier to repair." I think that that's kind of old science and wrong medicine now. But people do tear.

Dr. Hill: They do. And so, again, an episiotomy, they're still performed for appropriate indications. That does increase the risk of some of these symptoms after birth. But, at the same time, it's just because you maybe had all of these, a big baby, and an operative delivery. That doesn't necessarily mean you're going to experience any of these symptoms. And so, sometimes, that's how all these risk factors are joined together with your genetics, and how your body repairs after injury, and things that we can't control for.

Dr. Jones: Well, having a new baby can be a wonderful turning point in a woman's life. But, if your body isn't getting back to normal, and you're having problems down there after your vaginal birth, you don't have to grin and bear it. We're here to help. And thanks for joining us on The Scope.

Dr. Jones: As human beings have evolved, our big brains evolved to be bigger than our pelvis has evolved to be bigger. So births have become a little harder with a few more long-term consequences for women. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Healthcare and this is the scope of the problem of getting the baby out.

Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.

Dr. Jones: It has clearly been an advantage for humans to have a big brain. So with the big brain comes a big head. Today in The Scope studio I'll be talking to an expert on the pelvic floor, Dr. Ingrid Nygaard. She is a professor at the University of Utah and a urogynecologist, a gynecologist who specializes in pelvic floor problems. So what is the pelvic floor really? Not something you scrub with Ajax or something but give it to us.

Dr. Nygaard: No, definitely not. It's one of those important structures that we appreciate only really when it's not functioning as well as we wish it would. The pelvic floor is made up of the muscles, ligaments, connective tissues and nerves that support our internal organs, like the bladder, the uterus, the vagina, rectum. The pelvic floor muscles run from your pubic bone at the front to the base of your spine at the back. They're shaped like a sling and they hold your pelvic organs in place.

Dr. Jones: So it's kind of like a sling or a hammock but you don't want it too sling-y. You don't want it too hammock-y. You want it to be strong. So all these muscles and connective tissues keep our insides in. What happens when a baby comes out that way?

Dr. Nygaard: Well, as you can probably imagine, to allow the baby to pass through, the structures in the pelvic floor all have to stretch quite a bit. Luckily our body starts preparing for this long before labor even starts. But the pelvic floor muscles sometimes weaken after childbirth and then they weaken further as we get older.

Dr. Jones: Well, women give birth vaginally all over the world but why do some women have problems after vaginal birth and some don't?

Dr. Nygaard: Well, we know that weakened or dysfunctional pelvic floor muscles can cause problems down the road, like bothersome leakage of urine or pelvic organ prolapse where one or more of the pelvic organs bulges into the vagina. But for most women these conditions don't happen until they're middle aged or older. We don't know very much about how young women experience changes in their pelvic floor function after childbirth. It's probably fair to say that most women notice some minor changes after giving birth but the fact that most women who deliver vaginally don't have long lasting problems speaks, I think, to how amazing our bodies really are.

Dr. Jones: So as young women they may have the original insult or the original maybe even damage but that really doesn't show up until ageing and gravity and time adds its little mix to the potion. Is that how it goes?

Dr. Nygaard: Right exactly.

Dr. Jones: Right. So if women have a problem after vaginal birth, could it get better on? And so you're suggesting that these they don't notice it or maybe it gets better on its own?

Dr. Nygaard: No, absolutely it could get better on its own. A lot of processes go on in our bodies that encourage healing and recovery after childbirth. Over the first couple of months for example, the uterus goes back down to normal size and the pelvic floor muscles start regaining their strength, and this means that symptoms that some women notice after childbirth often go away within a few months. If it doesn't get better, is there anything we can do to help? Well, we're lucky that time alone helps many women recover well after childbirth but we don't know very much about other factors that might help women recover well after vaginal delivery. But one thing women can do to help get the pelvic floor back in shape after delivery is pelvic muscle exercises. Some people call those Kegel exercises. I encourage women who notice some urinary leakage for example, to do these. It's a good idea to have someone give you some guidance to make sure you do these correctly and effectively, and a great resource for this is a women's health physical therapist and you can also ask your doctor or nurse for tips.

Dr. Jones: Oh and they're really easy to do. I just did them. I can do them while I'm even talking on The Scope radio right now and I don't have to hold my breath and my face isn't getting red.

Dr. Nygaard: It's not getting red.

Dr. Jones: But someone in the studio is kind of laughing. Oh, okay, well let's talk about does childbirth cause any problems over the long-term? We talked about that a little bit.

Dr. Nygaard: Well, over the course of her lifetime about one in five women undergoes treatment, often surgery, for pelvic floor disorders. Childbirth is one thing that can contribute to this but there are many other factors too from ageing to nerve problems like strokes to obesity and genetics plays a role as well.

Dr. Jones: I read somewhere that female paratroopers had a little more prolapse but that's just an aside. So what kind of research are you involved with regarding these problems in childbirth?

Dr. Nygaard: That's amazing to consider the fact that even though nearly four million women deliver baby in the US every year, most of them vaginally, there really hasn't been much research about how to maximize recovery after childbirth in terms of pelvic floor health. So we are conducting a study called the MAPH study, which is short for Motherhood And Pelvic Health, and the goal of the study is to find out what we can recommend to help women recover well after vaginal delivery. We're specifically looking at how things like physical activity, intra-abdominal pressure and muscular strength influence pelvic floor support and symptoms during that first postpartum year. We see this research as an important step in crafting prenatal and postnatal regimens that will promote better pelvic floor health. We're planning to enroll about 1,500 women across the Salt Lake Valley. Our participants are all first time new moms and we're so grateful to them for lending us their time and involvement to help us learn about pelvic floor health after childbirth.

Dr. Jones: So for those of you who are still having babies or about to have your first, the good news is that it goes mostly just fine and for you ladies who have some long-term consequences of getting those babies out, there's hope and there's help, and thanks for joining us on The Scope.

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Dr. Miller: Could you have a pelvic fracture? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. David Rothberg. He's an orthopedic surgeon and specializes in trauma care. David, how would one know if they had a pelvic fracture? Now I know that these are fractures that don't just occur spontaneously. Generally, people will have some type of trauma. Tell us a little bit about how that happens. How does one suffer a traumatic pelvic fracture?

Dr. Rothberg: There really are two separate patient populations that will have a pelvic fracture. One is the patient with a devastating life-threatening injury. These are not ones where you're questioning. These are patients that come in as a Level 1 trauma activation, but really a lot of these come in in an older patient population who have had a ground-level fall. They've tripped on the carpet, or over a dog, or something like this, and they can have pain anywhere from there groin, their abdomen, or low back, and that's when the work-up starts.

Dr. Miller: Is it sometimes confused with a hip fracture?

Dr. Rothberg: Commonly. The type of pain that you have with those two fractures is extremely similar, and we typically will figure out which one it is by taking x-rays.

Dr. Rothberg: Now a pelvic fracture, I guess depending on the type of patient, generally those are surgically repaired. They're fixed and treated, and then there's a recovery period. What about a pelvic fracture? How do you treat those? It seems like it would be kind of hard to cast a pelvic fracture.

Dr. Rothberg: Yeah, that's true.

Dr. Miller: It's like a rib. You can't cast ribs.

Dr. Rothberg: We don't cast pelvic fractures. What we're trying to figure out when we're working up some of the pelvic fractures is is the pelvis stable or unstable? And what that means is how much motion is in the pelvis when someone would walk.

Dr. Miller: And how do you determine that?

Dr. Rothberg: It's based on physical exam, the x-rays, and oftentimes a CT scan really looking at the pattern of the fracture, or how the bones are broken, and trying to determine the best course.

Dr. Miller: So in a pelvic fracture, would you operate on them from time to time?

Dr. Rothberg: Yeah, it's a very common operation for us. We do them almost daily, if not weekly. It really depends on the age and patient health status and mobility, and a lot to do with what they've broken.

Dr. Miller: Is the recovery time similar to a repaired hip fracture, or is it longer? Is there a difference in the type of recovery?

Dr. Rothberg: It's pretty much in the same ball park depending on the pattern of fracture they had. The surgery is a little easier to recover from. The surgery is not as invasive, but the ability to get back walking is about the same. It's tough in the early period, but we do expect that most people will get back to their daily life.

Dr. Miller: So the real key is if someone falls at home, especially an older person, and they have persistent pain they ought to be checked out and receive some type of radiologic study in order to determine at least initially if there's a fracture.

Dr. Rothberg: That's exactly right.

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Interviewer: If you're missing time from school or work or relationships because of severe pelvic pains, it could be endometriosis. We'll examine that next on the Scope.

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Interviewer: Fatigue, excessive pain during periods or intercourse or with bowel movements or urination, excessive bleeding and infertility. These are some of the symptoms of endometriosis. And 10% of women have this condition and some don't even realize it. Our goal for this podcast is to raise awareness to this condition and help you figure out if you might have it. Dr. Joseph Stanford is with University of Utah Health Care. Are there some other symptoms, did I miss anything?

Dr. Stanford: Those were the main symptoms. You covered it well.

Interviewer: So, why don't women realize they have this condition? I find that kind of surprising at that thought.

Dr. Stanford: A lot of women think that having pains with periods is normal or just something they have to deal with or they may go to the doctor that says, "Well, we'll see how it goes. Let me put you on the pill and see how you feel." And they don't really look into what might be the underlying issue.

Interviewer: Is this pain just during periods or is it all the times during the month?

Dr. Stanford: The biggest pain is during periods but sometimes it will get so severe that it's at other times of the month as well.

Interviewer: All right. I was reading some stories about women who have been diagnosed with the condition and I notice kind of that theme that you mentioned that sometimes doctors don't necessarily recognize the condition. Is that common?

Dr. Stanford: It's often they may not recognize it or they may just feel like, "Let's try something simple," and then try to deal with the symptoms because the only way for sure diagnose endometriosis is a surgery. So, it's understandable that sometimes doctors would be reluctant to mention that possibility.

Interviewer: Yeah, I got you. And some of these stories that I was reading also kind of led me to believe that women who know they have it, at some level, knew they have it because it's excruciating. Is that pretty accurate as well?

Dr. Stanford: Often, but I would say there's a spectrum of symptoms. Some women have milder symptoms, and they may still have the conditions.

Interviewer: So, those milder symptoms, how do you know what's normal and . . . because pain threshold, that's a very personal thing.

Dr. Stanford: I would just say pain with periods that interferes with your life, that's not normal.

Interviewer: So, many women have these terrible symptoms before they get diagnosed and treated. What causes endometriosis?

Dr. Stanford: There are a lot of theories about it, a lot of research going on, but at this point, we really don't know for sure what the causes are.

Interviewer: Do you know if it's a lifestyle issue, is it something that a woman's doing or not?

Dr. Stanford: I wouldn't say it's a lifestyle issue, there may be some environmental exposures, there may be some genetic factors.

Interviewer: Okay, all right. So, what exactly is going on? We've talked a lot about the symptoms, what is it? What's happening?

Dr. Stanford: What's happening is that tissues that are normally on the inside of the uterus called the endometrium, that tissue gets on the outside of the uterus or another part of the pelvis or other parts of the body where it's not supposed to be and it causes problems, inflammation, pain, problems.

Interviewer: I think you mentioned the only way to deal with that at this point is surgery?

Dr. Stanford: The only definitive way to get rid of it is surgery. There may be medicines to reduce the symptoms, yes.

Interviewer: All right. I understand that sometimes these conditions can be misdiagnosed as irritable bowl syndrome or IBS. Is that common?

Dr. Stanford: That would be common. That's a disease that could be confused with it, yes because irritable bowel syndrome would have some of the same symptoms.

Interviewer: Yes. How would you differentiate between the two if you're a woman.

Dr. Stanford: Well, if the symptoms are particularly around the menstrual period, the menstrual flow and if the symptoms are with intercourse, you definitely should be thinking more about endometriosis.

Interviewer: All right. So, other than the misery and compromising quality of life, are there other reasons that a woman should be treated for this condition.

Dr. Stanford: Yes, in the long run, it can reduce fertility if she is wanting to have children. Also, there's some indication that it may be linked to some future cancer risks.

Interviewer: Is there anything I left out, anything that you feel compelled to say, anything that you feel a woman should know about?

Dr. Stanford: Yes. Most women with endometriosis could go for many years before they get it diagnosed and I would say that if you're having symptoms, it's better to get looked at sooner than wait.

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