Menopause and Beyond

Heather Marra is a pelvic floor physical therapist and author, based in Lexington, Kentucky, with over 25 years of experience helping women reclaim their health and quality of life. She is the author of two books — one focused on connecting with your body during pregnancy, and True Intimacy: Embracing a Woman's Sexuality, written on her 50th birthday to address the widespread but often silent issue of painful sex. Heather specializes in the full spectrum of women's health, from pregnancy and postpartum to perimenopause and beyond, and currently sees patients at 109 Dennis Drive in Lexington. Her mission is to ensure no woman suffers in silence — whether from pelvic pain, prolapse, hormonal changes, or intimacy issues — by giving them the knowledge and tools to advocate for themselves. Her contact information:

http://www.heathermarra.me

http://www.linktr.ee/onesimplesteptoday

Transcript

Speaker 1 0:00

This is no filter, no boundaries. Good morning, Heather Marra.

Speaker 0:11

Good morning.

Speaker 1 0:12

It is very good to have you on the show today. Heather is an author and pelvic floor physical therapist. That is such a unique thing, and I'd never heard of until I heard of you.

Speaker 0:24

And you think that the need is there.

Speaker 1 0:27

Definitely, definitely. I've told so many people about you since the first discussion we had. Now you have worked with women all across the spectrum of life, from pregnancy, postpartum, perimenopause, and beyond. What has surprised you most when you started specializing in the menopause space?

Speaker 0:48

I would say the common response that I get from women is, what's happening? I don't feel like myself, and a loss for information and such a huge confusion about this midlife shift.

Speaker 1 1:02

Okay. You said women deserve shame-free, holistic pelvic health. How did you, on your own personal journey, navigate perimenopause yourself?

Speaker 1:13

Well, I sought out a provider that specialized in menopause medicine. I didn't just settle for the answer of this is just aging and you have to just push through it. I found somebody that specialized in menopause medicine, and then I see her every three months. And it's tweaking what I need from supplements or bioidentical hormone and taking control of my life for the power of lifestyle changes, like helping my nervous system reset. And so all these things are intentional steps that we as women need to do through this midlife shift.

Speaker 1 1:52

Yeah, instead of ignoring the problem and saying, oh, this is just normal.

Speaker 1:56

Yep. Or I'll just get through these hot flashes and then life will get better. Some of these symptoms in menopause will actually get worse if left unattended.

Speaker 1 2:07

Oh, I do believe that. I do believe it. And just when you think the hot flashes have left, they're back.

unknown 2:13

Yes.

Speaker 1 2:15

So here's something that I thought was interesting. Most people have heard of Kegels, but what's actually happening to the pelvic floor during menopause that makes it such a critical time to pay attention?

Speaker 2:26

So one big key in menopause and perimenopause, which can start even as early as 35. So women say, Oh, I'm too young for this. I'm like, no, no, no, no, pay attention. We start to have this roller coaster effect, this chaos of hormones where we have some drop. It might be a sudden drop, it might be a fluctuation, but you just don't feel like yourself. Estrogen receptors are everywhere in the body, but they are very concentrated in the vaginal area. So when we have that drop in estrogen, then we have changes like pain with sex, vaginal dryness, nighttime urination, even prolapse, decreased libido, all these things that wait a second. This is a new chapter, what's going on? And it goes back to mostly estrogen drop. There's other hormone changes too, but we need to pay attention to these changes that are going on.

Speaker 1 3:21

I agree. And you just said pelvic organ prolapse. That's something that I really hadn't heard of. But can you uh explain how common this actually is?

Speaker 3:30

Definitely. So let's I'll try to draw this out visually. I usually use my pelvic model, but think about the vaginal cavity going up. On either side is the rectum, and on the other side is the bladder, and on the top is the uterus. And so with pelvic organ prolapse, there can be a laxity and a weakness. So any one or all those drop vaginally. And then a woman says, Oh, I have a heaviness feeling or a fullness. Maybe it's after a full day of work. I worked with one bank teller that said, like about two o'clock, I start to have this heaviness and I want to sit down. Um, and so what we're feeling is this bulging or heaviness that just did not feel normal per se. And that could be some laxity. And there are different stages, one to four on a pelvic organ prolapse. But knowing that, wait, what do we need to do at this time? Do we need to strengthen? Do we need to talk about vaginal estrogen cream? Do we need to talk to our provider? There's a lot of different treatment options for pelvic organ prolapse rather than just ignoring it.

Speaker 1 4:37

Well, that actually leads to the next question. Estrogen plays such a huge role in our pelvic floor health. Can you help with walk us through what declining estrogen actually does to the pelvic floor, the bladder, and the vaginal tissue?

Speaker 4:52

Sure. So a drop of estrogen will cause some of the vaginal tissues to become more thin, like almost like cigarette paper, which means they're more fragile and tend to tear, which might cause some bleeding with sex or some pain with sex. We don't the tissues aren't plumped up. We actually lose the labia menorah, the inner lips. Some women say, Oh my goodness, they disappeared. I lost them. What happened? But let's backtrack to this. When we were born, we didn't have our labia menora. When we went through puberty, estrogen kicks in and the labia menorah are formed. We go into menopause and we drop that estrogen, and that's when we the labia menorah kind of fuse into the labia majora or just change. So all those physical changes that you can see also impact decreased blood flow, decreased muscle strength, which cause more leakage, more urgency, and decreased sensation or more difficulty, even having an orgasm. All those things fall into this global vaginal changes of menopause.

Speaker 1 6:03

Awful. And the painful sex, is there anything that's most effective that can help with this?

Speaker 6:10

One, I would say pelvic floor physical therapy. I wish every woman would go and see a pelvic floor physical therapist, just like you would be seeing your doctor or your dentist taking care of your eyes. You got to take care of your pelvic floor. A lot of times I see women with tight pelvic floor muscles from either scar tissue, um, surgeries, vaginal deliveries, or just neglect. So releasing some of those pelvic floor muscles can help. Sometimes it's a weakness, uh, sometimes it's a tightness. Pelvic floor physical therapy is one thing. And then using it in conjunction with vaginal estrogen cream, which will actually regenerate the tissues. We've got to have these conversations rather than one, putting up with these symptoms and not telling them anybody about them, or two, getting dismissed by a healthcare provider that you know has just 12 minutes and this is not even one of the key things that they're focusing on. And yet women are saying, I'm changing down there. What can I do? Oh my gosh, yes.

Speaker 1 7:15

So, how much of that work do you think is physical versus psychological? Do you address both?

Speaker 7:20

I think it's really both. Uh, we as women can't just go in and treat the pain with sex and release the tension because sex is so mental. Um, and if we had a history of some pain or sexual trauma in the past, we have to create trust again with the body that this is safe and the muscles can relax. If the muscles can't relax, and we go back to the same cycle that's going through our brain in the past, our body guards, say your husband comes close to you and you just tense up. Well, pain sex is going to be painful, and we can't even talk about producing lubrication or even getting the point where it's enjoyable and you're able to have an orgasm. And I walk through all of that with each woman as I evaluate and treat, because I'm not just treating her pelvic floor, I'm treating the whole woman.

Speaker 1 8:16

So, what does a pelvic floor appointment for menopausal woman look like?

Speaker 8:21

Sure. So a lot of times women come in here um almost like deer in the head, like uh, I don't know what I'm doing. But I treat women in a beautiful, warm setting. So it's private. It's not like you're going into a pelvic um or a physical therapy gym. And then I explain a lot of things of what's going on. Tell me about your symptoms. Everything about bowel, bladder, and sexual function all plays into this. I don't want to dismiss anything. And then I ask more questions. Then I have my pelvic model to understand where's the pelvic floor. It's not just a black hole down there, it's between our legs and there's muscles and there's ligaments and understanding the function. And then asking if there's been a past history of any sexual trauma, also, because I want to honor that woman and offer trauma informed physical therapy where you're in control. And this is different than going to say you're OBGyne with a speculum. I don't use that. I'll say, are you comfortable with doing a pelvic exam today, or do we need to wait till the next time? And with permission, then I'll have her take her underwear and pants off, cover up with a sheet, then I'll walk back in and start working on the belly with I've got gloves on, I'm working on the belly, doing scar massage release, breathing. And then I look at the pelvic floor muscles externally and start comparing how does the left side feel to the right side? Is there tension? Oh, there's pain with that. Oh, there's tenderness from a scar, um, from maybe a vaginal delivery and a tear years ago. And we address that. And then going internally, those pelvic floor muscles I'm assessing. I want to work on any tension and also mobility and strength. So, yes, you'll do a kegel, so I can tell you exactly how to do a kegel. Um, and women are like, oh my goodness, that's what my Pilates instructor has been trying to tell me. That's my pelvic floor. So we're connecting the dots, and then through that whole process, I may assess rectally, say you've had a fall on the tailbone, have difficulty sitting in a hard chair, or through a um vaginal delivery, there is some birth trauma as well. And so I'll address all of that. You have permission, you get to call the shots, and if we're done, we stop for that day, and then you get a home exercise program as to what specifically you need to work on, because so many things that you can do between those pelvic fluorophysical therapy appointments. So each one is unique, but it's very thorough evaluation and treatment.

Speaker 1 10:57

Oh, yeah, because every woman is totally different. So, with all the hormone therapy, pelvic PT, and lifestyle changes, how do you help women navigate? Do you give referrals for those women that specialize in hormone therapy?

Speaker 11:13

Yes. So again, walking through these questions of are you on bioidentical hormones? Or no, I've been told I can't do them. Well, let's see if you need to find maybe a nurse practitioner that specializes in menopause medicine, and it's the holistic look at it, or maybe that you need to see a counselor or a sex therapist. They it's holistic care. It has to look at everything, and everybody has a role and a place so that you can feel your life.

Speaker 1 11:46

And what do you think is the biggest gap now in the medical community and how they handle menopause?

Speaker 11:52

I think it's a lag in our research update. A lot of women are still living in the fear of the 2002 WHI or the Word Women's Health Initiative, where there was a connection between hormones and breast cancer and cardiovascular disease. And so women are still being dismissed and told, oh, you're not appropriate. There are so many options right now. Our research is coming so far and it's getting such publicity, but we have a shortage in providers, so it's being able to connect out there. And do I find somebody that's local in person? Do I make a virtual visit? So I think that's where some of our gap is because I think there's probably 10% of women are on bioidentical hormones right now. And that number should be a lot higher.

Speaker 1 12:48

Oh, yeah. And I just told you I went to my neurologist a few weeks ago and asked him about being able to use different types of estrogen since my heart attack and stroke. And he says, No, you can't use any, none. I was like, oh my gosh. Okay, second and third opinion.

Speaker 13:05

It really needs to be a shared decision conversation. You bring your symptoms, your concerns, your provider brings their perspective and you meet in the middle. So there are options out there. For example, say an estrogen patch bypasses the liver. So even if you had a history of blood clots, you don't want to take oral estrogen, but a blood clot uh but a estrogen patch may be a better option for you.

Speaker 1 13:35

That's interesting. So, do you want to tell us a little about your books that you've already written and what might be next for you on the horizon?

Speaker 13:45

Definitely. My second book came out last year, True Intimacy, Embracing a Woman's Sexuality, and really understanding your pelvic floor, understanding if there's pain with sex, what can be done between vaginal lubricants, moisturizers, and vaginal estrogen cream, and then understanding how to release your pelvic floor and how to strengthen your pelvic floor through the decades of marriage, because sex can change through all stages of life. Um, and women have really been appreciative that they don't feel like they're suffering in silence and they have a good resource that gives practical tips. So that was my second book. And my first one is connecting with your body throughout pregnancy. Um, and I wrote that during the pandemic when women were scared about birthing by themselves and needing a lot of information, lots of practical tips on both of those. That's where a couple of the resources that I have. And then I also see women right now in Lexington at 109 Dennis Drive. And being able to run my own practice that's Cash Base. I take HSA and FSA, but providing that one-hour visit one-on-one and really fine-tuning each visit for each woman and being thorough to unpack what's going on physically and surgery and their symptoms. And it is uh, it really is life-changing. And that's why I've been doing this for 25 years.

Speaker 1 15:16

And that's why I wanted to introduce you to my girlfriends and every woman that's out there. They need to hear your message and they need to make an appointment. Maybe we can and even encourage some young women to become pelvic floor physical therapists.

Speaker 15:30

We need more. Oh, most definitely. That needs the need is there. At one time, I think in Kentucky, we had one pelvic floor physical therapist for 16,000 women. Obviously, a shortage. And if we're talking about the younger generation, let's have this conversation so that women are looking at menopause as a pre-menopause conversation in your 20s and 30s. What are you doing about your lifestyle, your bone density, your protein, your pelvic floor? Let's address things early instead of just waiting until they culminate 20 or 30 years later. Let's have this conversation with our daughter, daughters and our granddaughters, and let's make menopause and the midlife shift a normal conversation about women's health. Women's health includes sexual health. It includes the leakage, it includes all these things that we need to be discussing instead of being scared to even bring it up.

Speaker 1 16:32

Oh, yeah. Some women I feel are even scared to talk to their own husbands about the problems that we're having, really. Oh, yes.

Speaker 16:38

I've had those where I don't even know if he knows that I'm having painless sex. I'm like, oh, well, let's start this conversation. I can give you some resources to even start that what I call a windshield conversation. So that you have these conversations. Or I have husbands come into treatment. So I'm like, let me explain the pelvic floor. And this is what I need you to do as a pre-sex routine, not medicinal, but it can be uh deepening the intimacy as well as releasing the pelvic floor, as well as increasing enjoyment. And it's a win-win for everybody.

Speaker 1 17:12

Oh, I love that idea. That would definitely help. Instead of it coming from the wife, maybe coming from a specialist, they might listen to us.

Speaker 17:20

Exactly. And then there's a lot of homework to do, and he tends to be um anxious and eager to complete the homework.

Speaker 1 17:27

Oh, yeah, that's good homework. Well, Heather, I appreciate talking to you so much. It's always a pleasure. And thank you. I hope that we will have you on again soon with my panel of crazy menopausal women.

Speaker 17:43

Exactly. And again, you can follow me at one simple step today on Instagram or Facebook or YouTube as well, and reach out to me. I would love to have a conversation. I'd love to see you either in person or virtual. Um, and my email is heather at onesimple step dot today. So let's continue this conversation.

Speaker 1 18:07

Let's do. Thank you. Have a great weekend. You too. Thanks. And you are listening to No Filter, no boundaries.