For Women’s Health

From go to ‘ohh!’ Sex across the lifespan

FOOD FIGHTERS PMS AND PMDD Foods that fight the What you can do about ‘flame’ of inflammation premenstrual symptoms Women’s health. Powerful stuff.

Sept 6 – 10 2021

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Jean Hailes is supported by funding from the Australian Government. Contents VOLUME 1 2021

04 12 22 Jean Hailes Reduce your Ask Dr Jean news prolapse risk Your health Latest news, Symptoms, questions book review strategies and answered by pelvic floors our experts 06 Food 15 23 fighters Sex across Recipe Foods to fight the lifespan Sweet potato 15 the ‘flame’ of What to expect toast piled From go to ‘ohh!’ inflammation – and how to with goodness roll with the 08 changes “The fact is that PMS and women go on PMDD 19 merrily bonking Help for Your stories premenstrual A woman into their 80s.” symptoms shares her PCOS 11 diagnosis story Clinic tips How to get the 20 most from your Research doctor visit Key insights 08 Writers: from our 2020 PMS and PMDD Nerissa Bentley Women’s Gina Flaxman Health Survey Muriel Reddy “... once they get Jo Roberts their period, it’s like Design: a switch has flipped Alexandra Clark Cover illustration: back to normal.” Michelle Pereira

Our Commitment Acknowledgement Connect with Jean Hailes Jean Hailes is Jean Hailes for Women’s Subscribe to our email update and receive committed to bringing Health gratefully acknowledges the latest women’s health news at you the most recent the support of the Australian jeanhailes.org.au/subscribe evidence-based Government. information. twitter.com/JeanHailes All articles go through Every donation counts facebook.com/JeanHailesforWomensHealth rigorous review with Secure donations can be made youtube.com/JeanHailesFoundation experts. References are online at jeanhailes.org.au instagram.com/JeanHailes available upon request. or call toll free on 1800 JEANHAILES (532 642) jeanhailes.org.au

JEANHAILES.ORG.AU 3 Jean newsHailes

COVID-19, our clinics and Hot Doc Clinicians at Jean Hailes proved their ability to pivot in 2020 when the COVID-19 pandemic affected face-to-face consultations with patients. “We have always been very patient-led,” says Kay Perkins, practice manager of the two Jean Hailes clinics at East Melbourne and Clayton. “A key to our success is giving patients and clinicians choice.” One choice patients embraced in the face phone to video calls,” says Ms Perkins. “Clear of the pandemic was telehealth, which allowed communication and the ability of the patient them to have their consultations via phone or to explain the issue to the doctor was really video from the comfort of their own homes. important to the process.” While Jean Hailes had offered telehealth for In March, Jean Hailes also launched its online several years, its popularity soared as people booking system, Hot Doc, enabling patients were forced to isolate due to COVID-19. to book appointments any time, without the In the first week of April 2020, when need to phone. “It streamlines the process and Melbourne was in lockdown, there were 236 enables the patient to see a doctor’s availability telehealth consultations and zero face-to-face. at the touch of a screen,” says Ms Perkins. The popularity of telehealth continued to grow through August with 255 recorded Learn more about Hot Doc compared to 98 face-to-face consultations. and our clinics “Our rural patients tended to prefer the

Women’s Health Week update Emily Quattrocchi, our latest inspiring. A dedicated Women’s Health Week cheerleader, Emily returned to ambassador, knows what it’s like competition within a year of her to battle against the odds. accident, becoming Australia’s Nearly three years ago, a first para-cheerleader. car accident in her Victorian She has also built a hometown of Euroa left Emily professional life as a producer with a T4 spinal injury and a of films and YouTube vlogs. minor brain injury. Her documentary film, Emily Although she felt crushed, – you never give up, has been emotionally and physically, shown at film festivals here and during her seven months of internationally. recovery, Emily learnt that life She believes it’s important Emily and her mother was far from over. “I realised I am for women of all abilities to Lyn Newnham. capable,” she says. be part of discussions about Photo: Mark Jesser Her achievements are women’s health.

Join Emily for our ninth annual Women’s Health Week at womenshealthweek.com.au

4 VOLUME 1 2021 HEALTH PROFESSIONAL UPDATE An updated ‘Menopause management’ e-learning course is now available on the Jean Hailes website. The RACGP and ACCRM-accredited course, which has been developed with assistance from Jean Hailes subject matter experts Dr Sonia Davison and Dr Fiona Jane, aims to support health professionals by providing up-to-date advice and treatment in the care and management of menopausal women. The course will help health professionals to effective menopause management plan identify the signs and symptoms of menopause, tailored to a woman’s presentation and history. outline key points in consultation and diagnosis, This now completes a suite of three evaluate benefits and risks of menopausal e-learning courses for health professionals hormonal therapy (MHT), and design a safe and available on our website.

Learn more about our e-learning modules

Control. For many thorough yet highly but also insights from women going through engaging book are other women (and room menopause, it’s often respected clinical for you to jot down what they feel they’re psychologists in the UK. your own). The book losing, as menopausal Hunter and Smith have comprehensively covers symptoms gnaw away worked together since menopausal symptoms, at their quality of life, 2008 to develop CBT- and societal and cultural in body and mind. based treatments for views, before moving However, cognitive menopausal symptoms, into behavioural and behavioural therapy testing them in clinical cognitive strategies BOOK REVIEW (CBT) – a type of trials and sharing to manage symptoms Living Well psychotherapy that can this evidence-based such as stress, hot Through the help people to change knowledge with women flushes and problems Menopause: unhelpful behaviours and health professionals with sleep, sex and and ways of thinking (Google them for other concentration. An evidence- and feeling – has publications). It concludes by inviting based cognitive earned huge merit as This book not only women to cement their behavioural guide a way for women to gives women practical goals and plan how to By Myra Hunter and wrestle back control skills and strategies maintain them. Highly Melanie Smith of their lives from to help them cope recommended. Little Brown, 2021 menopausal symptoms. with bothersome Available via $16 (e-book) $37 (print) Both authors of this menopausal symptoms, booktopia.com.au

JEANHAILES.ORG.AU 5 Fight

What is an anti- the ‘flame’ inflammatory diet? An anti-inflammatory diet involves avoiding or limiting foods that have been shown with food to increase inflammation, and increasing your intake of foods What you eat can help reduce your risk of that reduce it. inflammation that can cause chronic disease “Growing research suggests – and it’s easier than you think. that reducing certain foods may be helpful for both the symptoms By Gina Flaxman and long-term health outcomes associated with chronic disease,” says Dr Baume. e all know what [type 2] diabetes, heart disease Sugar is particularly happens when and arthritis,” says Dr Brukner. inflammatory and consuming a wound or joint “It may also be a factor in the high amounts can lead to obesity, becomesW inflamed: there is development of dementia and insulin resistance and type 2 swelling, redness, heat and pain. Alzheimer’s.” diabetes. Dr Brukner, who is “Inflammation is a protective In the case of atherosclerosis the chair of advocacy group immune response designed to – a build-up of plaque inside SugarByHalf, says the “hidden help the body clear an irritant the arteries and the cause sugars” found in products such and heal from trauma,” says Jean of most heart attacks and as fruit juice and packaged Hailes GP Dr Dominique Baume. strokes – Dr Brukner says the foods are particularly harmful, as In the case of an injury, the focus is now moving from the people often aren’t aware they’re inflammation protects us from impact of cholesterol to that of consuming them. “About 70- infection and tissue damage. inflammation. “We now know it’s 80% of all processed foods have This is inflammation we can see. the inflammation that attacks the added sugars,” he says. “We’re all familiar with artery walls,” he says. “The Western diet of highly this acute inflammation,” says Dr Brukner says lifestyle processed foods tends to Dr Peter Brukner, a specialist factors such as poor diet, lack promote inflammation,” says sports and exercise physician of exercise, stress, smoking and Dr Baume. She says these foods and the author of A Fat Lot of alcohol have all been shown also often contain harmful Good, a book that examines to increase the body’s levels of trans fats. She says you should diet and health. chronic, low-grade inflammation. also reduce your intake of However, there is a type of “Traditionally, we’ve tried to treat saturated fats (deep-fried foods), inflammation we cannot see, inflammation with medications,” alcohol, soft drinks and refined known as chronic, low-grade he says. “But making lifestyle carbohydrates such as inflammation. This inflammation changes can have a dramatic white bread. has no external symptoms, but is effect on inflammation.” always there at a low level, says Dr Brukner, “just chipping away at things, creating long-term damage”. “Chronic, low-grade inflammation seems to be a major factor in the development of chronic diseases like

6 VOLUME 1 2021 Some medical experts also believe consuming too many Recipe vegetable oils results in an imbalance of omega-6 fatty Fish and acids, which may promote vegetable kebabs inflammation. To reduce inflammation, By Sandra Villella Jean Hailes naturopath focus on whole, nutrient- dense foods. Dr Baume says Serves: Makes 12 kebabs the Mediterranean diet is a Prep time: 30-40 mins good example of this. “This (plus marinating time) Cooking time: 10-12 mins diet is rich in green leafy Gluten free, dairy free vegetables, tomatoes, fresh fruit (strawberries, blueberries, Ingredients Place 1 tbsp of paste in a bowl cherries, oranges), extra-virgin 1 bunch coriander and mix with lemon juice. Add olive oil and nuts (walnuts and 2 cloves garlic fish to marinate. almonds), which are good Stir another 2-4 tbsp EVOO Generous pinch of salt sources of antioxidants,” into remaining paste, and she says. 1 tbsp turmeric powder toss through vegetables with Fatty fish such as salmon and 2 tbsp freshly grated ginger another 1/3 of coriander leaves mackerel contain omega-3 fats, Few grinds of freshly to coat well. Put fish and which are particularly good for ground black pepper vegetables evenly on skewers reducing inflammation. 1 tbsp tamari (any leftover vegetables can be Some believe fruit and cooked separately). 6-8 tbsp extra virgin olive oil vegetables from the nightshade Heat a skillet or BBQ grill to (EVOO) plus extra for cooking family, such as eggplant, medium heat, add splash of oil. tomatoes and capsicum, may Juice of one lemon Cook 10-12 minutes, turning trigger arthritis flare-ups, but 4 fillets of white fish every 3 minutes. Sprinkle with Arthritis NSW says there is (eg, trevally or snapper), remaining coriander and serve. limited evidence to support this. cut into 3-4 cm pieces “We just need to get back 2 zucchinis, halved Nutritional information to eating real food, the way our and sliced 1 cm thick Fish, vegetables and herbs grandparents used to eat,” I eggplant, chopped such as ginger and garlic – says Dr Brukner. GF 1 red onion, cut into 8ths they’re just what the naturopath ordered as part of an anti- 12 mushrooms, halved ’FLAME’-FREE inflammatory diet. FOOD AT A GLANCE Curcumin is the active anti- What to eat: A range of Method inflammatory ingredient in fresh, brightly coloured If using wooden skewers, turmeric, and its absorption can vegetables and fruit, oily soak in water first. be enhanced by cooking with oil fish, nuts, olive oil. Separate coriander leaves and adding black pepper. What to avoid: Sugary and from stems, finely chop While oily fish is often processed foods, refined separately. In a mortar and promoted as a top source of carbohydrates, alcohol. pestle, grind garlic with salt. anti-inflammatory omega-3s, Healthy swaps: Swap Add coriander stems and the Heart Foundation website vegetable or soybean oil for 1/3 of leaves to make a paste. has a great resource that lists extra-virgin olive oil. Stir in turmeric, ginger, fish, seafood and plants from black pepper, tamari and the highest to lowest sources 4 tbsp EVOO, combine well. of the omega-3s EPA and DHA. Learn more about healthy eating Download the recipe from the Jean Hailes website

JEANHAILES.ORG.AU 7 PMS and PMDD and you Premenstrual symptoms don’t have to be a part of life. There are treatments that can help.

By Nerissa Bentley

or many women, the week before their When symptoms are more severe period can be difficult. For some, it can Along with physical premenstrual symptoms, be debilitating. But the good news is between 3-8% of women experience Fthat premenstrual syndrome (PMS) and its debilitating mood or psychological symptoms close relative, premenstrual dysphoric disorder that interfere with their daily lives and even (PMDD), can be treated. prevent some women from holding down a job. This is known as premenstrual dysphoric What is PMS? disorder (PMDD). PMS refers to a broad range of physical Jean Hailes endocrinologist Dr Rosie and emotional symptoms experienced by Worsley says PMDD is a subset of PMS that women in the days leading up to their period. refers specifically to very severe mood or Up to 90% of women experience at least one psychological symptoms, particularly depressive symptom most months, with 50% of women symptoms and irritability. experiencing several symptoms each month. “Typically, the pattern is that women feel Symptoms can start anywhere between 4-10 really unwell in the week before their period,” days before menstruation, and often resolve says Dr Worsley. “They may have very low once bleeding begins. moods and experience a lot of fatigue, but once Some of the most common symptoms include they get their period, it’s like a switch has been bloating, fluid retention, breast swelling and flipped back to normal.” tenderness, headaches, skin problems, lethargy, There are no tests for PMDD, so diagnosis is constipation and/or diarrhoea, as well as determined by the pattern of symptoms, usually mood changes. However, there are many other over three cycles. The key difference between symptoms women may also experience. PMDD and depression is that symptoms get “There are over 200 different symptoms better once menstruation begins. associated with PMS that have been reported,” “You can use an app or a journal to track says Jean Hailes naturopath, Ms Sandra Villella, symptoms,” says Ms Villella. “Tracking them “but women typically experience the same set under different categories will help you notice of symptoms from one cycle to the next.” certain patterns. For example, you might ask

8 VOLUME 1 2021 Pictured: chaste tree (also known as chaste berry and vitex agnus castus)

‘do I have generalised anxiety, or is it that I’m a baby, and closer to menopause, as these just anxious in the pre-menstrual phase?’ events can change the way some women’s “By definition, symptoms need to occur brains react to these hormones.” on one or more of the five days before menstruation, appearing in the previous Treating and managing three menstrual cycles, and have to dissipate PMS and PMDD within four days after the start of menstruation. The good news is that PMS and PMDD can be If symptoms continue, then it’s probably treated and managed successfully, although not PMDD.” sometimes it can take trial-and-error to find what works. What causes PMDD? Contrary to popular belief, PMS and PMDD Natural remedies aren’t a result of high or low hormone levels, Lifestyle changes such as regular physical but rather an increased sensitivity to hormones activity, using alcohol sensibly, reducing stress, in the lead-up to menstruation. This sensitivity avoiding smoking and maintaining a healthy is caused by an interaction between hormones weight can all make a difference. from the ovaries and brain neurotransmitters, Ms Villella says vitamin B6 (between 100mg which influence mood. and 200mg) has also been shown to be effective The exact causes of this sensitivity aren’t and is considered part of the first line of fully understood, but several factors may treatment for PMS. increase the risk of PMDD. “While the research to support the use of B6 “PMDD is largely genetic,” says Dr Worsley. for PMS is limited, it has been shown to have a “Rates are also higher in women who have significant impact on the central production of experienced early childhood trauma or have a both serotonin and GABA-neurotransmitters history of depression. It can occur after having that control depression, pain perception and

“[PMDD] can occur after having a baby, and closer to menopause, as these events can change the way some women’s brains react to these hormones.”

JEANHAILES.ORG.AU 9 anxiety,” she says. “It’s best taken as part of a implant under the skin to ‘turn off’ the ovaries B-complex.” – is an option that will work if others have not. However, Ms Villella warns that higher doses don’t equal greater benefits – in fact, far from it. What else can you do “Doses over 200mg can lead to irreversible Both Ms Villella and Dr Worsley say that being nerve damage, so it’s really important for aware of your symptoms, when they occur and women to speak to their health practitioner how they make you feel can help you plan and before taking B6,” she says. make sure you don’t do too much during this Ms Villella says chaste tree (also known as phase. It’s also important to educate your chaste berry and vitex agnus castus) can reduce family about the issue, so they can support you. mood swings and irritability. Cognitive therapy can also be helpful. “It has the most convincing clinical data “Talking to someone can help, either by out of all of the botanicals for efficacy in addressing underlying issues or coming up the treatment of PMS,” she says. “It’s highly with strategies for those days,” says Dr Worsley. effective, but needs to be prescribed by a health practitioner trained in herbal medicine.” When to seek help Other natural remedies that have some Dr Worsley urges women to speak to their clinical evidence of relieving PMS symptoms GP if they experience premenstrual symptoms, include lemon balm, magnesium and calcium. as these conditions can be successfully treated. However, before taking any supplement, “There is actually quite a bit of research speak to your health practitioner to ensure going on overseas now, so I really think the correct dosage, and to avoid adverse reactions next 10 years are going to provide women with other supplements or medication you’re with more hope, better treatments and more already taking. This is especially so for St. John’s understanding of what’s going on with PMS wort, which is often used to treat depression. and PMDD.” NB

Medical treatment 3 THINGS TO KNOW Women who don’t respond to lifestyle remedies and natural therapies may need further medical 1. PMS refers to a broad range of physical advice. Dr Worsley says treatment will depend and emotional symptoms experienced on symptoms and whether there are other by women in the days leading up to underlying conditions. their period. As many as 90% of women “If we’re talking about PMDD and severe experience at least one symptom. irritability or low mood, and often bad fatigue, 2. PMDD is a subset of PMS that refers they may have separate period issues,” she says. to very severe mood or psychological “Because we don’t have specific treatments, symptoms, particularly depressive I tend to screen everybody for factors that symptoms and irritability. PMDD can might be making them worse, such as thyroid impact a woman’s life significantly. issues, low iron or endometriosis and treat those 3. There are many lifestyle, natural and things. Other treatments can include anti- medical therapies available that can help. depressants which are about 70% effective, as You don’t have to suffer in silence. well as hormonal options like the pill and MHT [menopausal hormone therapy].” While these treatments will work for most women, Dr Worsley says medical menopause Learn more about PMS and PMDD – the use of medicines, such as a nasal spray or

10 VOLUME 1 2021 Appointment reminders

Do you find you’re not leaving the doctor’s surgery with everything you need – or need to know? Here’s a few tips on how to put that right.

By Muriel Reddy

Take a friend Get to know your GP It can help to take notes or, if It helps if the doctor and patient Dr Amanda Newman you are nervous about receiving get to know each other over diagnosis news, to bring along a time. “I can track changes partner or friend. Sometimes you in their appearance, which More than 22 million of us visit don’t hear all you are being told. could potentially be related a GP every year – proof that the to health issues, physical or doctor/patient relationship is Be honest emotional wellbeing,” says Dr one of the most important in “It’s important to be open Newman. “It allows you to open our lives. But it’s not always the and honest with the doctor,” conversations by saying, ‘what’s most rewarding. explains Dr Newman. “It’s going on? You’re not your How many of us have walked amazing how many people will normal self’.” out of the surgery only to scold tell you what they ought to be ourselves for not asking an doing rather than what they It’s a ‘partnership’ important question? Or for are doing. Insights from the patient are not admitting that we didn’t “It’s okay to ‘fess up the doctor always valuable. Increasingly, understand the diagnosis? that you’ve done something silly says Dr Newman, patients want Or for not asking for a new or incorrect. The doctor is here to to be involved in the decision- prescription? Or were so help, not to judge you.” making process around their nervous we heard only half health. “Some people wish to of what the doctor said? Google can help be given the facts and then There is a cure for this. It divides opinion but Dr Google accept advice from experts,” You can get the best from can sometimes be helpful to she explains. “Others want to your visit to the GP by being the consultation process. be given facts and options. prepared for it. And there are “Dr Google has been a blessing “Some want to make steps you can take to do that. and a curse,” says Dr Newman, all the decisions about their “… but it can lead to a more care, and this means there has Make lists robust consultation. to be relationship of trust Dr Amanda Newman, a Jean “If a patient comes in and between the doctor and the Hailes specialist women’s health says, ‘Dr Google says I might patient, but the doctor also has GP, suggests making a list of the have pancreatic cancer’, I to trust the patient. This is a questions you want to ask and can address that information. partnership.” MR carrying a list of the medications, Sometimes they might suggest Learn more about how to including complementary, you something helpful. Patients’ get the most out of your are taking. Report any allergies opinions are important, but they doctor’s appointment you might have. are not always correct.”

JEANHAILES.ORG.AU 11 Lifting the lid on prolapse Training your pelvic floor muscles throughout life can reduce your risk of prolapse.

By Muriel Reddy

Every woman is at risk of pelvic organ prolapse, yet most of us find it too embarrassing to talk about. “It’s about the genital area and it’s private,” explains Jean Hailes urogynaecologist Dr Payam Nikpoor.

What is prolapse? Prolapse happens when the muscles supporting a woman’s pelvic organs – the bladder, uterus and bowel – weaken and cause one or more of those organs to drop. Women often report the feeling of a bulge or a pressure in the vagina; like a feeling that they are sitting on an orange or a tennis ball. Sometimes they will notice tissue sticking out of the vagina. Two of the more common symptoms of prolapse are the leaking of urine (wee) or faeces (poo), known as urinary and faecal incontinence. The Continence Foundation of Australia estimates that one in four people in Australia are incontinent, meaning they have trouble controlling their bladder and/or bowel.

12 VOLUME 1 2021 Some women can experience Train the pelvic floor urinary problems such as slow Ms Webb believes it is helpful stream, a feeling that they are for women to train their pelvic not completely emptying the floor muscles throughout all bladder. Others suffer from the stages of their lives – after urgency and stress urinary childbirth, at menopause and in incontinence. Bowel problems the later years – even if they do can develop when women suffer not have issues. Women who do from constipation, or a feeling of experience prolapse will need not fully emptying the bowel. a tailored intensive pelvic floor program. This has been shown What causes prolapse? to reduce symptoms. They will For women who experience also be given correct techniques prolapse, it will usually occur for bladder and bowel emptying. after menopause, from the ages Ms Webb says many women of the mid-50s through to the fear they will be unable to return 70s. “However, what we know is to the sorts of physical activities that childbirth is a risk factor,” they have always enjoyed, but says Dr Nikpoor. “So too is this is not necessarily true. constipation, obesity, people who have chronic raised intra- “Undergoing a pelvic abdominal pressure [straining], floor training program and and chronic cough.” Ageing and adopting some lifestyle a family history of prolapse are also risk factors. advice can reduce or Women with prolapse can eliminate symptoms.” experience pain during sexual intercourse. Others report a lack “There’s a device that has of sensation during intercourse. been developed that allows Not all women with bulge women to continue with will need surgery, but they will regular forms of exercise while need to see a physiotherapist monitoring its impact on their and learn pelvic floor exercises, pelvic floor,” she explains. “It’s and may need to make healthier inserted into the vagina and has lifestyle changes. a little Bluetooth monitor that tucks into your undies. Speak up early “It’s suitable for anyone who Early intervention is key in wants to train [their] pelvic floor the treatment of pelvic floor and monitor what’s happening prolapse, says Jean Hailes pelvic during exercise.” floor physiotherapist Janetta Webb. “It’s important for women What you can do to talk to their GP if there’s Making lifestyle changes any change to their bladder or can lower risk factors of bowel function,” she explains. prolapse. Dr Nikpoor says “Undergoing a pelvic floor these include eating healthily, training program and adopting exercising regularly, keeping a some lifestyle advice can reduce normal weight, and avoiding or eliminate symptoms.” constipation. This lifestyle

JEANHAILES.ORG.AU 13 HOW TO STRENGTHEN YOUR PELVIC FLOOR approach, along with pelvic Start practising this exercise daily, either sitting or lying down floor muscle exercise, is the on your back with your knees bent and feet flat. This is easiest conservative approach to on your bed or couch. treatment. If this doesn’t work, Learn more about pelvic floor exercises health professionals will consider the next steps in management. Steps What to do Next steps • Tighten the muscles around the anus, vagina Dr Nikpoor says he always and urethra all at once and try to lift or draw considers the use of vaginal them up inside pessaries – supportive devices • Make sure you are not pushing down, that hold the prolapsed organ holding your breath or squeezing your in place – before surgery.

Tighten buttocks or legs together Neither uncomfortable nor • Nothing should be working above the belly painful, pessaries come in a button, but you may feel your lower abdominal range of shapes and sizes to suit muscles switch on. the type and degree of prolapse. Once inserted, they require • Slowly count to 3 regular monitoring. • Let your muscles go completely – this should “They can be managed either feel smooth and quick and the muscles should by a pelvic floor physiotherapist, stay relaxed while you rest a continence nurse or a • Rest your pelvic floor muscles while gynaecologist,” Dr Nikpoor says. you count to 6 “They can stay for as long as they

Level 1 • Repeat are effective – for the rest of their • Do as many as you can up to 10 lives if they work. • If you find it difficult to let your muscles Surgery is considered the go, softening your belly and letting your last management option. “This abdominal muscles go might help, as well involves procedures that would as quiet, relaxed breathing. reinforce the supporting tissue in the pelvis to rectify the Please note, if you have an issue with vaginal prolapse,” says Dr Nikpoor. MR or pelvic pain, you will need a special program from a pelvic floor physiotherapist before 3 THINGS TO proceeding any further KNOW • Instead of counting to 3, slowly count to 6 or 8 • Let your muscles go completely 1. Pelvic floor muscle training • Rest and relax your pelvic floor muscles while is important at all stages you count to 6 or 8 of a woman’s life. Level 2 • Repeat 2. See your doctor if there’s a • Do as many as you can up to 10 or 15 change to your bladder or • Rest a minute. Then try some shorter, hard bowel function. squeezes. Tighten hard then completely 3. Pelvic floor muscle training let go straight away. Build up to doing 20 and a healthy lifestyle can of these in a row. reduce the risk of, and symptoms of, prolapse. After you have done 10 of the level 2 exercise, do some really strong squeezes – as strong as you can, then let go. Level 3 Do as many of these as you can, up to about 10. Learn more about prolapse

14 VOLUME 1 2021 Sex from go to ‘ohh!’

Through the course of a lifetime, a person’s sex life will ebb and flow. It can help to know what changes to expect - and how to roll with them.

By Muriel Reddy

ex is good for you. It lifts and emotional influences of sex is like … [it] puts a lot of your heart rate as well as menopause can impact not just pressure on women, particularly your pleasure-boosting women, but their relationships. young women.” Sendorphins. It can make you feel “Life has ups and downs,” says We know teenagers are happy and – hold the eye rolling Ms Matthews. “We need to get sexually active. According to – it can feel good throughout that information to women rather data provided two years ago all the ages of womanhood. Sex than allowing them to (believe in) in the Longitudinal Study of does not belong to the young. a Disney fantasy.” Australian Children, one in three “The fact is that women go on The sexual expectations teenagers had engaged in sexual merrily bonking into their 80s,” placed on women today are intercourse by the age of 16-17. says sex educator and columnist demanding and, according to Dr King says girls who want to Maureen Matthews. leading sex therapist Dr Rosie delay intercourse will instead The sexual journey is not, King, pornography is partly to perform oral sex on their however, without challenges. blame. “It is not reality,” she says. partner. “They don’t want to Differences in libido, painful sex “It is entertainment and it shows go all the way, so they see [it] as and the effects of childbirth, child a very unrealistic portrayal of a normal part of pre-intercourse rearing as well as the physical what women enjoy and what activity, foreplay.”

JEANHAILES.ORG.AU 15 In the beginning Dr King sees in practice. At the start of a woman’s sex “A study done in the UK life – or the beginning of a reported that 15% of men new relationship – couples reported a lack of interest “often cannot get enough of in sex compared to 35% each other” says Dr King, “and of women,” she says. “It’s they expect it to stay that way probably the same here.” forever.” This is known as the It can be complex to treat. ‘limerence’ period – or courtship “Often there are numerous phase – but it always ends. reasons why women are less interested in sex,” she explains. “As Jerry Seinfeld said, ‘women “The message to all women need a reason to have sex, men would be regardless of your just need a place’. age or the stage of your “You can expect mothers with life, you owe it to yourself babies and young children to have low interest in sex for a very – for good pelvic health – good reason – they are tired. to be well-versed in your If they are breastfeeding, they vulval and internal anatomy” have high levels of prolactin which switches of the sex drive and makes the vagina dry.” “When couples come to see me, that’s their expectation Libido – the clinical view – that they will get back to what There is a huge range they had in the beginning,” says in what is a normal libido. Dr King. “After limerence, you Several factors influence it, get desire discrepancy.” says Jean Hailes endocrinologist Dr Sonia Davison. They include Desire discrepancy long-term relationships, This occurs when one partner lower general health, care is dissatisfied with the level of of dependents (elderly and/ sexual engagement and the or children), working, as well other partner feels pressure. as the contraceptive pill and It is the most common issue antidepressants.

16 VOLUME 1 2021 “Lots of women are doing your vulval and internal all those things and expect anatomy,” she says their libido to be as rip-roaring Half of the women seen as it was in their 20s,” says Dr by Ms Webb have weak RECOMMENDED Davison. “It’s often the first thing – or underactive – pelvic floor READING to leave the building. Libido is muscles while the remainder around so we can procreate and have overactive muscles. This Come as You Are as we age, it becomes less of an is common in adult women of by Emily Nagoski imperative.” all ages and can be triggered She believes it’s important as a defence mechanism to Mating in Captivity for women to recognise what pain – for example, women with by Esther Perel makes them happy in terms of endometriosis often experience sexual function. “If there is a pain during sex. More than half Sex for One change that distresses you, seek the women Ms Webb sees every by Betty Dodson [professional] advice because day have issues with painful sex. there are options out there,” Love Worth Making she says. Painful sex by Stephen Snyder Vaginismus (involuntary vaginal Pelvic floor tightening when penetration Well-functioning pelvic floor is attempted) is one of the muscles are thought to help most common problems that with increasing pleasurable Associate Professor Wendy sensations during sex. “If women Vanselow sees as head of orgasm, the pelvic floor muscles psychosexual medicine at contract and that increases the Royal Women’s Hospital pleasure,” explains Jean Hailes in Melbourne. “There are pelvic floor physiotherapist a lot of women who have Janetta Webb. “But we need difficulty in consummating their our pelvic floor muscles to work relationships and who can wait effectively.” years to come in [for treatment],” Training of those muscles is she says. “Often it is because key. “The message to all women they don’t know where to go.” would be regardless of your age Some women experience pain or the stage of your life, you owe during intercourse because of it to yourself – for good pelvic vulval pain, including vulvodynia health – to be well-versed in (a burning or sore feeling around

JEANHAILES.ORG.AU 17 “Using vaginal moisturisers two or three times a week can help 3 THINGS TO with vaginal dryness.” KNOW Women can also discuss with their doctor the use of 1. You do not have to endure menopausal hormone therapy pain during sex. Talk to (MHT) to treat menopause your doctor. symptoms including vaginal 2. Childbirth, motherhood, dryness. and menopause can all the vulva). “There are so many impact your sexual desire. causes for that and again we are What women want 3. Good pelvic floor trying to use more topical pain Dr King says it is a myth to health is good for sex. relief and physiotherapy.” suggest older women don’t want Start exercising those Assoc Prof Vanselow says or need sex. “They may not be muscles. See page 14 to many issues – diabetes, chronic able to do what they did when learn how to strengthen illness, menopause – impact they were 20 … but they can be your pelvic floor. on a woman’s sexuality. “Older creative,” she says. women particularly, but not Many women – young and solely, can have libido issues,” old – find creativity in the use of Learn more about she says. “Lots of contraceptives sex toys. Chris Joseph, chief of sex and sexual health can have an impact on libido and operations of online adult store, that needs to be taken seriously Randy Fox, says that a survey of and investigated.” 2000 customers last year revealed that 42% were women, while After menopause products designed for use While most postmenopausal by women accounted for women can have sex without 62% of sales. difficulty, some can experience a shrinkage of the vaginal The final word entrance as well as a loss of Sex matters. To many women, lubrication. This can lead to it’s the cornerstone of a pain and discomfort during relationship. It provides not intercourse, but there are just sexual gratification, but solution, says gynaecologist also intimacy. They are needs and Jean Hailes medical director that can ebb and flow over the Dr Elizabeth Farrell. “Women life journey, but they can be as can try a lubricant or some oil vital to an 80-year-old as to an – olive or sweet almond – or 18-year-old. MR they can be prescribed some vaginal oestrogen which will increase bloodflow,” she says.

18 VOLUME 1 2021 t age 23, Elicia has just been told she has the ovulation, hormonal disorder conceiving polycysticA ovary syndrome a baby (PCOS). “I have lived with without medical this silently for six years,” she assistance can explains. “It was so awful being sometimes be difficult. in the dark.” Aware of her concern, PCOS can affect as many as her partner encouraged Elicia to one in 10 women of reproductive have a complete medical check. Nevertheless, the diagnosis age. Symptoms include irregular “It had always been hard to still “crushed” Elicia. periods, excess facial and body find a doctor who would take “I went into a deep and dark hair, scalp hair loss, acne, weight me seriously,” she says. “I was depression,” she recalls. “I lay in gain, and difficulty getting not trying to have a baby, but I bed and bawled my eyes out. I pregnant. Elicia experienced really wanted to know what was didn’t sleep. I couldn’t eat.” some, but not all of these happening with my body. Thankfully, time has been symptoms (each person’s healing. As she began learning symptoms can vary greatly). “I honestly hoped he about PCOS, Elicia was directed Yet it took some time for the to the Jean Hailes website. professionals to join the dots. would say, ‘you haven’t got She was surprised to learn how At the age of 14, Elicia was it’. But in one way it was a common PCOS is, and it made put on the contraceptive pill to relief because I finally had her feel less alone. She now control her acne. An abnormal a name and I could say, makes a monthly donation to cervical screening test two years ‘I have this’.” Jean Hailes for Women’s Health. later made her stop taking it. “I am beginning to come to She also had a history of terms with this,” she says. “I irregular and painful periods. “I wanted someone to explain cannot change it and there is no “I got my period once every to me why I was not having a cure. I know I will have to get past five or six months,” she recalls. period but had symptoms. some hurdles to have a baby, but “I decided to see another doctor And I always had hair on my I know too it will be well worth it.” who told me I had post-pill chin and chest which really amenorrhoea.” (Amenorrhoea is embarrassed me.” Donate to Jean Hailes the absence of periods which can Elicia’s new doctor sent her for Women’s Health at occur in some women after they for blood and urine tests as well jeanhailes.org.au/donate stop taking the contraceptive pill. as an ultrasound. Elicia, who works as a haul The news of her PCOS truckdriver in the mines, has diagnosis hit her hard. Learn more about PCOS always wanted to become “I honestly hoped he would a mum. Despite not using say, ‘you haven’t got it’. But in protection during sex, pregnancy one way it was a relief because Want to share your own women’s hadn’t happened, so she was I finally had a name and I could health story? Email us at worried. Since PCOS can affect say, ‘I have this’.” [email protected]

JEANHAILES.ORG.AU 19 Research Women’s Health Exploring women’s Survey health issues and concerns.

Our sixth annual National Women’s Health Survey provided revealing insights into how women in Australia coped during one of the hardest years of our lives. More than 9000 women aged 18 or older and living in Australia responded to the 2020 survey, with Federal Health Minister Greg Hunt describing the results as “sobering and powerful”.

Physical & mental health one in three women (33.2%) reported feeling anxious

Professor Jane Fisher, AO, Finkel Professor of 28.7% Global & Women’s Health at Monash University reported feeling said the level of psychological distress revealed depressed 24% in the survey findings was of public concern. of women aged 25-44 said they Women struggling with this distress can talk to were drinking more alcohol their GP about a mental health care plan. They than before COVID-19 will be entitled to Medicare rebates for up to 10 individual and 10 group appointments a year.

Reproductive & maternal health

Despite the fact that 282 families every day of women aged 25-44 lose a baby to miscarriage, the loss was “not said they would consider validated as real grief”, said Samantha Payne, 35.6% freezing their eggs to CEO and co-founder of The Pink Elephant have children later in life Support Network. Jackie Mead, co-CEO of Red Nose, of women who suffered another support organisation, said women miscarriages said they did who had just been told their baby had 60% not receive enough information died were usually too shocked to take in or support information about possible support.

20 VOLUME 1 2021 Health needs & Intimate partner health information violence

Jean Hailes CEO, Janet Michelmore AO, urged women to take time for themselves, to focus on their health, to catch up on delayed screenings, one in four and “to use evidence-based information to support their decisions”. women (23.9%) experienced some form of intimate partner violence over the previous 12 months Top 5 health topics women want to know about:

1. Anxiety (34.8%) one in 10 women (11.1%) 2. Weight reported having a controlling partner. management (32.4%) This rose to 18.9% for women with a disability, and to 15.3% for those who 3. Healthy reported a worse financial situation than eating/nutrition (30.9%) before COVID-19 4. Mental and emotional health (26.3%) Ross Joyce, CEO of Australia Federation of Disability Organisations, said, “we all need to 5. Bone be held accountable to do more and address these key health issues for all women, and for health/osteoporosis (17.6%) women with disability in particular.”

A woman experiencing domestic violence 39.1% in any form and in need of support can call 1800-RESPECT. It operates 24 hours a day. or more than one in three respondents who identified Otherwise, she can go to 1800respect.org.au as women with a disability, could not afford healthcare If you are in immediate danger, call 000. when they needed it

31.7% Want to know more? For more information on topics covered here: of women aged 25-44 did not have enough time Anxiety to attend health check Healthy living appointments Miscarriage Stillbirth 31.1% Intimate partner violence of women in rural & remote regions could not get medical appointments when they View the the full survey results needed one

JEANHAILES.ORG.AU 21 Ask

Your women’s health questions Dr Jean answered by our experts. When it comes to women’s health, there is no such thing as a silly question. Answering your questions for this edition of ‘Ask Dr Jean’ is Jean Hailes endocrinologist and president of the Australasian Menopause Society, Dr Sonia Davison.

Q. I had a natural but very symptomatic menopause 10 years ago. Just over a year ago I had both ovaries and tubes removed due to a cellular fibroma on one ovary, I chose to keep my uterus. Since then I have been experiencing what I’d describe as a 2nd menopause, not quite as intense as the first one but just as debilitating. Is this normal? I’d been advised prior to surgery as I’d already ‘menopaused’ I shouldn’t experience any impact. Dr Sonia Davison A. When both ovaries are removed after menopause has occurred, the main difference Q. Hi, I’m 51, have PCOS and still menstruate hormonally will be a 50% or more reduction in as usual. No other medical issues, but I did androgen production. The main androgen is have fertility treatment to get pregnant. testosterone. This hormone goes on to produce I have noticed for the last year that when oestrogen so my presumption is that your body I wash and comb my hair, I’m losing a lot. is reacting to the change in testosterone levels My ponytail is easily half its usual thickness and the flow-on effect that this is having on and although I had very thick hair, I seem already low oestrogen levels. to be losing hair all over, so no one has Find out more about noticed. There are no bald patches according testosterone and menopause to my hairdresser. I’m just a bit worried that I will continue to lose hair and it will Q. Hi, Just would like to know what l could become obvious. Any idea what is going on? take for headaches before my periods. Genetics? Perimenopause? Thanks so much. A. This is a question to discuss in detail with A. I suspect that you are perimenopausal your GP! There are many types of headaches, and there has been a net overall reduction and it’s important to know if your headaches in oestrogen levels as you approach are migraines, and if there are any atypical menopause. PCOS can be associated with features, which would preclude some types of higher testosterone levels, hence the net loss treatment, eg, the oral contraceptive pill. Usual in oestrogen coupled with the possibly higher pain-relief measures such as anti-inflammatory testosterone levels may be contributing to medications like ibuprofen, or paracetamol the hair loss. But other pathologies such as would be first line of management. If ineffective, iron deficiency or thyroid dysfunction need and if the headaches aren’t atypical migraine, to be ruled out; stress may also be a culprit. then hormonal modulation may be useful, eg, Genetics and family history are also important. the oral contraceptive pill. I recommend seeing your GP and investigating Find out more about further. The information sheet ‘Patterned Hair headaches Loss’, on the Better Health Channel website, is an excellent resource for further information. Find out more about Ask Dr Jean a question patterned hair loss

22 VOLUME 1 2021 This wholefood ‘BLAT’ is ideal for breakfast, lunch Recipe or a light dinner.

Sweet potato BLAT (bean curd, lettuce, avocado and tomato)

By Sandra Villella Jean Hailes naturopath Serves: 1 Prep and cooking time: 30 mins Vegetarian/Vegan option. Gluten free, dairy free

BLAT ingredients BLAT method Nutritional information 2 slices sweet potato Peel or scrub sweet potato, A variety of brightly coloured slice into ½ cm pieces vegetables are a major part ¼ avocado lengthways. Toast in toaster on of a diet promoted as anti- 2-4 teaspoons gomasio highest setting, 2-3 times until inflammatory. This recipe (see recipe below) tender. This may take up to 20 includes almost all the colours 4-6 slices smoked tofu minutes, so prepare toppings of the rainbow, providing the or 2 slices salmon/trout in meantime. many different phytochemicals ¼-½ beetroot grated (plant chemicals) that work Top sweet potato toast together to create anti- 1 carrot grated generously with avocado inflammatory properties. The Small handful rocket (spread or sliced). Sprinkle anti-inflammatory diet is often or basil leaves on gomasio (see below). about cutting processed foods 1 tomato sliced, Add several slices of smoked from our diet, and often gluten. or 3-4 cherry tomatoes halved tofu or trout/salmon. Layer with This sweet potato toast is a (or heirloom for more colour) grated beetroot and carrot, then bread-free option, and the Fine-cut nori green leaves, then tomatoes. smoked tofu a swap for bacon, Sprinkle tomatoes with extra creating a wholefood, gluten- gomasio. Garnish with nori. free variation of the BLT (bacon lettuce and tomato) toastie. Gomasio ingredients Gomasio method 1 cup unhulled sesame seeds Heat a non-stick frying pan or Gomasio (or gomashio) skillet on medium. Add salt, toss translates to ‘sesame salt’. 1 cup fine-cut toasted dried nori, in pan for a minute. Remove. It’s a Japanese macrobiotic or dulse flakes (a dried and toasted Add sesame seeds, stir non-stop seasoning used on foods instead red/purple type of seaweed) for 2-3 minutes until they start of table salt. It’s still salty but 1 teaspoon sea salt to crack/pop, but do not burn. packs extra nutrients, especially (or your salt of choice) Remove from heat. Add seeds, with this seaweed variation. salt and seaweed into a seed Seaweed has the important grinder/small food processor, anti-inflammatory omega-3 blitz until combined (do in fatty acid EPA. batches if needed). Store in an airtight container in the fridge Download the recipe from or cool dry place and use the Jean Hailes website instead of salt.

JEANHAILES.ORG.AU 23 Once you have finished with this We want magazine, please share it with someone to hear who may also enjoy it. from you! We’d love to hear from you. Please email us at [email protected] For further information, please contact About Jean Hailes From go Jean Hailes for Women’s Health Head Office Founded in 1992 in honour of an extraordinary medical Toll free: 1800 JEAN HAILES (532 642) practitioner, Dr Jean Hailes, Jean Hailes for Women’s Email: [email protected] Health reflects the enduring legacy that Jean made to women’s health. She had a far-sighted vision to to ‘ohh!’ The Jean Hailes Medical Centres for Women improve the quality of women’s lives and give them Phone: 03 9562 7555 practical information based on the best available Email: [email protected] evidence. She is credited with being the pioneer of menopause management in Australia. Magazine inquiries Today, Jean Hailes is one of Australia’s leading and Jo Roberts most trusted women’s health organisations. Our work Phone: 03 9453 8999 is built on four pillars: education and knowledge Email: [email protected] exchange; clinical care; research; and policy. We aim to translate the latest scientific and medical evidence to help inspire positive change in women and girls by jeanhailes.org.au improving their physical health and wellbeing. Jean Hailes for Women’s Health takes a broad and inclusive approach to the topic of women’s health. This magazine generally uses the terms ‘women’ and ‘girls’. These terms are intended to include women with diverse sexualities, intersex women, and women with a transgender experience.

Terms of use If you wish to be removed from our mailing list or would like to update your contact details, please contact us on 1800 JEAN HAILES (532 642). This magazine is environmentally sustainable. This magazine is designed to be informative and educational. It is not intended to provide specific medical advice or replace advice from your health practitioner. © 2021 Jean Hailes