A truncated version of this article was published in National Women’s Health Network March/April 2019 The Women’s Health Activist Newsletter
We women tend to address the needs of everyone ahead of ourselves. We nurture our significant others, feed the kids, walk the dogs, pick up groceries, clean the house, while simultaneously navigating employment. As we address the needs of a multitude of layers that impact personal and family flow, we tend to overlook one of the most significant, how we physically feel. And while we are all aware of the basics in women’s wellness screenings to address breast, heart, diabetes, and menopausal health concerns, current wellness exams seldom effectively evaluate one of the most common conditions impacting women, pelvic organ prolapse.
Pelvic organ prolapse (POP) is the biggest secret in women’s health. Simmering beneath the surface of female empowerment, millions of women navigate symptoms that indicate a condition most have never heard of. POP is shrouded in stigmatized silence and estimated to impact up to 50% of women. Women mid-teens through end of life. Women of all races. Women of all sizes. Women in every socio-cultural demographic. The stigma that shrouds POP in silence is unsettling and unacceptable.
““I was shocked to hear how common it was and ashamed that as a country we don't do more to prepare women for the after effects of child birth. We owe women more education, more support, and less stigma wrapped around this problem.”
DO, New Jersey
The quality of life effect of POP is far reaching, impacting women physically, emotionally, socially, sexually, as well as in fitness and employment. Most women aren’t aware POP exists prior to diagnosis, and that is problematic. The intent of women’s wellness screening is to identify and address common or invasive conditions in early stage of development. But how can women pro-actively seek diagnosis and treatment for a condition they aren’t even aware exists?
“One of the most gratifying aspects of being a urogynecologist is caring for a patient who believes she is the only person in the world with pelvic organ prolapse. Realizing she is not alone is transformative for the patient's psyche and emotional well-being.”
S. Abbas Shobeiri, MD, Professor of OB/GYN, INOVA Health System
Women’s wellness screenings typically include a routine pelvic exam. Two of the most physically altering life events women experience, childbirth and menopause, are the leading causes of POP. Yet POP screening is not standard practice. What’s wrong with this picture?
The status quo for POP awareness and wellness screening hasn’t changed meaningfully since illumination via the Kahun Gynecological Papyrus nearly 4000 years ago. Discovery upon diagnosis is the norm for most women. Pelvic exams are considered the gold standard in female wellness protocol, but women are seldom informed of or effectively screened for POP during their routine pelvic exams.
“You hear of and try to prevent major life-changing diseases and conditions such as cancer, Alzheimer's, osteoporosis, etc. All I had ever heard of pelvic organ prolapse before it consumed my life starting in my early 30s was when a friend once joked about her grandma having to shove her uterus back inside of herself. I didn't believe such a thing was actually possible; it didn’t even make sense. I also never realized how isolating it could be to be so "broken" physically. I don't have a pink ribbon, a hashtag "me too", or any clichés about being a warrior or strong. No, I just take extra restroom breaks and decline exercise groups with female coworkers.”
Beyond childbirth and menopause, a multitude of lifestyle, behavioral, and co-existing health conditions compound risk of pelvic organ prolapse in women mid-teens through end of life, including heavy lifting, chronic constipation, chronic coughing, hysterectomy, genetics, hard foot-strike fitness activities such as marathon running or jogging, or any of several comorbid conditions including multiple sclerosis, Marfan, Ehlers Danlos Syndrome, spina bifida, or bladder exstrophy.
When most women discover a bulge of tissue pushing out of the vagina looking somewhat tumor-like, they panic. While women find urinary incontinence frustrating, they often believe it is a symptom that comes with childbirth or aging and is simply a “fact of life” they need to tolerate. Chronic constipation is incredibly common with POP, but when brought up in wellness visits, women are typically told to eat more fiber, drink more water, and get more exercise. And what about vaginal pressure? Fecal incontinence? Rectal pressure? Pain with intimacy? Inability to start the urine stream? Lack of intimate sensation? Tampons pushing out? No one tells women that these symptoms mean something, that they have significance, that they are flags that something is not functioning properly in their pelvic cavity. And unfortunately, women are seldom asked the appropriate POP symptom questions during the little time clinicians are expected to perform routine pelvic exams.
“Knowledge is power, and a woman should have all the information she needs to make an informed decision about her body.”
Roger Dmochowski, MD, Asso Surgeon-in-Chief, Vanderbilt University Medical Center
The steps to stimulating awareness of POP are taking too long. Which is related to the ineffective open dialogue about pelvic organ prolapse at the diagnostic level. Which is related to inadequate POP diagnostic clinician curriculum. Which is related to lack of academic evolution in the gynecologic sector. If our gynecologists, primary care physicians, midwives, and other healthcare clinicians who provide pelvic exams aren’t educated on the prevalence of POP and the need for routine screening, how is the status quo ever going to improve? We need to talk about pelvic organ prolapse. We need to talk about pelvic organ prolapse OUT LOUD. Considering the estimated 50% prevalence, POP is undoubtedly an aspect of female health that should be routinely screened for, diagnosed, and treated, just as heart health, breast health, blood pressure, and blood sugar is. Silence should no more surround vaginal and pelvic health than any other aspect of women’s wellness.
As in every under-recognized aspect of health, we don’t know what we don’t know. Every single woman newly diagnosed with or suspecting she has POP because she’s Googled her symptoms online, must travel down a diverse path of self-discovery. Five types of POP, four levels of severity, numerous types of POP occurring simultaneously, diverse symptoms that may or may not occur, the list of variables goes on and on. The only universal denominator with POP is the fact that it occurs to women. Women world-wide suffer in embarrassed silence. We must draw back the curtain veiling the biggest secret in women’s health.
The next significant shift in women’s wellness awareness, screening, diagnostic protocol, and policy is a whisper away. It’s time to take pelvic organ prolapse out of the closet.