Investigating Diabetes And Pelvic Health Interplay

Betsy Greenleaf, DO, FACOOG (Distinguished)

Thank you so much, Dr. Beverly. I am so excited to be here today.

Beverly Yates, ND

I am delighted to be a part of this. One of the things that I know is that you bring both that medical savvy along with your sense of humor and your approach, which makes people feel more comfortable and welcome. Many times when we are talking about women’s health and things to do with more balance, in particular insulin and the pancreas, diabetes, blood sugar regulation, core cortisol, and stress, people often get a little intimidated because some of these words are long and big. Meanwhile, the impact is profound. We are going to make this friendly so that the typical person attending the summit who is a member of the general public feels welcome, as well as talking to our colleagues and other fellow health professionals.

Betsy Greenleaf, DO, FACOOG (Distinguished)

That sounds great. I am ready.

Beverly Yates, ND

Super. Okay. Let us take it from the top. Can you explain the potential impact of diabetes on public health and how it manifests in individuals?

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes, the thing is, as a urogynecologist, I see diabetes all the time, and you would go, but you are not a diabetes specialist. But the interesting thing is, as an osteopathically trained physician, we were trained to look at the body as a whole system. When patients would come into my office complaining of leaking urine and maybe having a little itching, burning, and odor down there, my brain would automatically go, Well, wait a minute, it is not just their pelvic health. What else is causing that? Sometimes people do not even know that they have diabetes because of recurrent urinary tract infections, vaginal infections, sexual dysfunction, or leaking. We have to run to get to the bathroom and have a hard time holding it in. These are all things that can sometimes be presenting symptoms of diabetes in somebody who has not gone to the doctor for their regular checkup and had their sugars looked at. More often than not, I would end up finding it. The great thing was that they had symptoms. Now we could find it and then get to the root cause of their symptoms, which was diabetes, and then a lot of these conditions can improve once sugar control is achieved. Then I am able to direct them to a diabetes specialist so that they can get the help they need.

Beverly Yates, ND

That is great. Thank you for that. It is always interesting when a colleague has a specialty area like yours, urogynecology, and you are seeing people for those kinds of concerns. Sometimes you are the first person to diagnose that they have, type 2 diabetes or pre-diabetes.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes. Definitely. It was interesting because I looked at some of the statistics, too. In fact, let’s just talk about sexual dysfunction in both men and women. Diabetics have a 3–3.5% increased risk of having sexual dysfunction due to diabetes. In men, it may present as erectile dysfunction. In women, they present as, I specialize in women, so I can get to go a little bit deeper into that. But 79% of diabetic women will have sexual dysfunction at some point in their lives, and that is pretty high. 82% of men  will have sexual dysfunction if they are diabetic. With women, we see that as diabetics, 50% of that dysfunction is present in low desire, 47% in arousal dysfunction, 50% in vaginal dryness, and 42% in difficulty with orgasm. These are definitely topics that people get very embarrassed about. They just think, Oh, this is a normal part of aging, so I am going to just ignore it. They are saying, This is just the way things are, and I am going to just deal with it, when in fact there are tons of different therapies on the market that can be done for this. Just the fact that, getting sugar under control can help improve these symptoms.

Beverly Yates, ND

Absolutely. All of these things are so important. Thank you for calling out that list explicitly. I have always felt, as someone who focuses on things like diabetes, heart issues, and sleep, that we rarely, if ever, hear about some of these things that go on with sexual arousal and performance issues, pleasure, and satisfaction. They are not talked about in terms of blood sugar regulation. I think the general public needs a lot more information—factual information—about what causes what, so to speak. Let us continue to connect these dots because, of course, we are here together. We want to be sure that people understand. I hope folks are taking notes, and I kindly ask anyone listening to these sessions, particularly this episode, to share it with other people who want to know more about their health. We are uncovering some not-obvious stuff here and trying to make it more accessible to the general public.

Betsy Greenleaf, DO, FACOOG (Distinguished)

This comes like the chicken and egg because, as you mentioned, cardiovascular disease is so closely related to diabetes. But it’s that cardiovascular effect that, a lot of times, causes them difficulty with their blood flow. Well, this is one of the areas where we start seeing sexual dysfunction. A man with erectile dysfunction has a blood flow problem. If the blood vessels, especially the tiny little itty-bitty blood vessels, are not functioning properly because sugar has been known to cause inflammation, and the inflammation has now been called small vessel disease, this can show up as erectile dysfunction in men, and then in women, we get the same problem with vaginal lubrication. A lot of people think it is mucus. Well, it is actually a blood product. It is actually a fluid that comes from high blood pressure. I should not say high blood pressure. I will get it mixed up. But there is pressure in the pelvis from blood flow, and then it is almost condensation. It is the seepage of the blood products through the vagina that makes that lubrication. If the blood flow is not good because diabetes is affecting those small blood vessels, this is now where women will end up having problems with dryness and decreasing lubrication, and we will start seeing sexual dysfunction. A lot of times, the same thing happens with both men and women, but it is not always an early sign of diabetes. It is an early sign of heart disease, too, and then we can combine the two of them. We send them immediately to a cardiovascular doctor and their diabetic specialist.

Beverly Yates, ND

Absolutely, though, the interplay of these problems—sometimes it’s this overlapping set of circles, when it’s a Venn diagram thing—people can feel overwhelmed when this happens. When I am hearing you say, just to recap, that if someone shows up who has repeated urinary tract infections or chronic vaginal infections, they feel itchy, let us say that in their pelvic floor, in their vaginal area, and in the pubic area in general, there is a possibility that they also might have pre-diabetes with Type 2 diabetes, and they need to be evaluated for that.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes. Commonly, especially with both, let us say, men and women. Men, we talk about the ejaculate; women, we talk about candida and our vaginal infections. These are incredibly common among diabetics because candida, which is a yeast, loves sugar. If somebody’s sugar is really high, now we are starting to feed the yeast, and we are going to get yeast overgrowth. Now, normally, we have yeast on our skin and in our gut. But actually, I will tell you that the normal population tends to have about a 14% colonization of yeast on their body that does not affect them or cause any kind of infection, whereas diabetics have up to a 40% increased risk of colonization of candida. That means their yeast levels are much higher. We see this in the gut. We see this now: anything in the gut can then get to the vagina. Then get to the groin. Very commonly, I will say, people who have had not just a yeast infection, because that is common, go on antibiotics, which kill off the good bacteria that fight the yeast. The next thing you know, you have itching, burning, and a discharge.

But the problem that we see with diabetics, in particular, is that they get a yeast infection. They take all the medicines for it, and they get better. Now, within a week or two, the symptoms are back. So we are now going, Okay, well, here’s some more medicine, and then they get better. Then, within a week or two, it is back. It is that pattern of getting better but coming back—any better—that tells me that either we are not completely getting rid of the yeast or getting it down to a manageable level, or the sugar levels are now so high that we are constantly feeding that yeast, and the yeast is just partying and going crazy and multiplying. Interestingly enough, I see the same; this is where we connected, even with diabetes. I see the same pattern in women who are not diabetic around holidays like Halloween or Valentine’s Day, where people tend to overeat sweets. Even just the fact of overeating sweets could almost create this transient diabetic situation where you may not be clinically diabetic, but if you are overeating sweets, you may be raising those blood sugar levels, and then your body’s starting to react as it would if your blood sugar was not raised over time, as in diabetes.

Beverly Yates, ND

Exactly. Now that I have explained that, I am sure that people are connecting the dots and going, Aha! Or I wondered, or I never knew that. Wherever they might be on that spectrum of recognition. Now that we are thinking about this, what are the specific challenges that are faced by individuals who have diabetes regarding bladder and bowel control in relation to pelvic health?

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes.  Now we get into some more complicated things where you think about your bladder and bowel control until you have a problem, and then all of a sudden it’s, Oh no, what is going on? Because you think, for a lot of people, this can be even more embarrassing because people think, Oh, now I am starting to wear pads or diapers, and B, not being able to hold in the urine or hold the stool can be socially very awkward, but it is very, very common. In fact, as we age, we naturally increase our risk of incontinence. It is leakage, incontinence, leakage. Leakage of either urine or bowel contents increases as we age. In fact, there are more people walking around at any given point in their seventies who have what is called an overactive bladder, where they have to run to get to the bathroom because they cannot hold it in.

There are more people at any given time walking around in their seventies with that than with a common cold. But then we throw yes, then we throw diabetes at that, and the statistics are anywhere from a 13 to 20% increased risk for diabetics over the population. Would you look at those numbers? They don’t sound that bad. But when we look at them specifically, 40% of diabetic women will have bladder control issues. There was a paper that actually looked at that, and they looked at the patients that did have these bladder control issues, which could be urgency or frequency; we termed it got to go, got to go. All of a sudden, you are fine, and next thing you know, you are asking, Where is the nearest bathroom? You are going crazy trying to find it or leaking when you cough, laugh, and sneeze. Those are different types of urinary incontinence, or urine leakage. But in the study that looked at the number of cases that happened, especially in women, they looked at the ones where women got their sugar under control. They had up to a 50% improvement in their leakage episodes. Now there are tons of different medications, treatments, and therapies for everybody across the board.

But just focusing on the great work that you are doing is that if we can get sugar under control, we could be making this so much easier to live with. First of all, pads and diapers are very expensive, and if you are wearing a pad or a diaper all day now, that is moisture, and yeast likes moist environments. Now we are increasing our yeast risk. All together, if we can get all those risks down, this is going to be a better situation for everyone.

Beverly Yates, ND

Very well said. Thank you for pointing all those things out. Absolutely. With this in mind, I know people are going to be on your head going, Oh, wow, okay. Making all the connections you have touched on here. In fact, we have a few more things we are going to follow up on. Have you opened up this wonderful area of discussion? When we are talking about sexual dysfunction, specifically for diabetes, how does it contribute, and what strategies and treatments are available to address these issues? Because I am sure people are saying, Okay, now that I see it’s connected, what do we do about it?

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes, I mean, the biggest thing is, once again, going back to the root cause and getting those sugars under control as much as possible. Seeing a cardiologist to get the cardiovascular disease under control, and then we start getting into some fun things. Sometimes it is just, well, we need to increase blood flow to the pelvis. A lot of people have heard of Viagra. We see the commercials with the little blue pill. The interesting thing is that those medications can also be used by women. Sometimes women get very upset because they are. It is not fair. Men have their pills. We want our pill. But, and I will just call it as it is, as women specifically say to me, it’s not fair. We want a horny pill. I am, and Viagra is not a horny pill. It is a blood flow pill; all it does is make you take the medication and feel mentally stimulated, because honestly, our brains are our most important sexual organ. If the brain is not stimulated, nothing else is going to follow. The brain stimulation just triggers the blood flow in the pelvis to start flowing. With diabetics, that flow may be a little bit sluggish. You are not getting where you’re supposed to be. Doing something like taking Viagra may help. Using natural supplements like L-Arginine works very similarly to Viagra, but with those, we are both of those medications or supplements. You have to watch out if you check with your health practitioner to make sure they are safe for you to take because there are some medications that will interact with them.

Then we get into some of the other technologies, such as sound wave therapy, which is really fascinating because they use sound waves to actually apply a little device. It is almost like an ultrasound wand for the male or female genitalia. It sends out these little bursts of sound, and it is called acoustic wave therapy. Those little bursts of sound will break up plaque in the blood vessels. Years ago, this therapy was used to break up kidney stones, and people would have to get into those baths, and they would shoot sound waves at them, and it would break up their kidney stones. But they figured out a way to use the same therapy at a much lesser strength to apply it to the genitalia, to break up the blood vessels in the penis, in the vagina, and in the vulva, to actually help improve blood flow. That is something that has been really interesting, or even using PRP, which is platelet-rich plasma. That is actually taking your own blood, using the growth factors in your own blood, and extracting those out. The platelet-rich plasma, not the whole blood, but where the growth factors are, and then actually injecting it into the genitalia, will stimulate the growth of new blood vessels, so it helps with healing and helps develop new blood vessels.

This is actually really fascinating when it comes to regenerative therapies. Then, even for women, we have a bunch of other regenerative therapies when it comes to the thinning of the tissue. That naturally happens with age but tends to get even worse when you are diabetic when using lasers, which are just light energy. The light energy will penetrate the tissue, and it will actually trigger the body to heal itself. As the body is healing, it triggers, and it will actually trick, almost like biohacking the tissue into regrowing. Using lasers, and then they realized how lasers work and tried more soundwaves. They tried soundwaves that generate heat to do the same thing. The nice thing is, this is snowballing because we only started with one of these regenerative therapies in 2014, and as time goes on, the technology just gets better and better. There are so many options. These things are covered by insurance. Some of them are not. But the great thing is that you do not have to just sit back and be; all this is just a normal part of aging, or this is just what it’s like to have diabetes. There are answers, and life is too short to be miserable, not live your life, and be full. You are full of power. You might as well do whatever you can to live a full and happy life.

Beverly Yates, ND

Absolutely, pleasure is part of life. It is really good and so encouraging to know that people with diabetes have options to improve and restore sexual function and pleasure because it is a part of life. I think that this is one of those things that is on the Q-tip. It is really quiet. You do not hear people talk about this a lot, but this suffering is going on, and it is not necessary. Again, I have taken notes and making lists. You have options these days—safe, proven therapies that can make the difference and help to correct some of the local problems while you work on the bigger systemic whole-person issues of poor blood sugar control and glycemic problems.

With that in mind, Dr. Greenleaf, let us look at this next thing. You have also talked about the topic of circulation and circulatory flow. How the blood moves and how it has been compromised with diabetes: can you elaborate on the role of circulation problems in diabetes and how they affect pelvic health, particularly in terms of wound healing and infections?

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes. I mean, the thing is that our blood is bringing nutrients into all of our tissues. If our blood flow cannot get to an area because we have constricted blood vessels, wounds are not going to heal the way they should. Any time that there is a wound, especially when the sugar is high, and we know that when sugars are high, this is now an inflammatory reaction that will prevent not only the blood flow from getting and bringing these growth factors to where they need to be to stimulate healing, but if the sugar is high, it’s going to feed bad bacteria and yeast, which can contribute to infection.

It is interesting because I remember when I did one of my rotations as a medical student, and it was in ophthalmology, so it was the eyes. I remember when there were these little machines. When you go to the eye doctor, they look in your eye with a little machine, and they can see the back of your eyes. What was really fascinating is that in diabetics, we will see something called the column skip lesions, where the really micro vessels of the eye will show a little red line, which is your blood vessel. then there will be a space, and then there will be another red line, a space, almost a dash line, almost Morse code, because they get these little areas where the blood flow gets constricted. I was trained. That is one of the ways to diagnose diabetes in the back of the eye.

Now fast forward: as urogynecologists, we look inside people’s bladders all the time. I remember one of the times I was looking into someone’s bladder and they were diabetic, and I was going, Wait a minute, this bladder looks exactly what I remember seeing when we were looking in people’s eyes, and they could actually develop the same skip lesions in the bladder that we see in the eye from poor blood flow. How that affects it is that maybe the bladder does not regenerate as well as it should. It does not heal as well as it should. Bladder infections take longer to overcome. This is adding to areas of irritation because the bladder does not heal properly. It has a nice protective layer on it that keeps the irritation from the urine off of that bladder. But if now you are getting areas where maybe they are getting microscopic ulcers or microscopic cuts, it is almost along the lines of if you had a paper cut and I poured saltwater on it, you would be like, Oh, I am irritated where? Now this urine is getting into almost these paper-cut areas of the bladder. We can see diabetics with bladder irritation and bladder pain syndromes. This can be one of the factors that contribute to an overactive bladder or even spasm of the bladder.

Beverly Yates, ND

That is important to know because when people have these kinds of problems, it is often not clear in advance if there are good answers available or even a way to recognize them. I would imagine internally that the person is feeling very uncomfortable—maybe some jarring stabbing or shooting kinds of pain coming from a person or exercises that someone can do that help people. Who have diabetes to manage their pelvic floor muscles and avoid dysfunction or recuperate from dysfunction. If that is the case with the muscles of the pelvic floor and related issues, such as something you talked about earlier, which was urinary incontinence or pelvic pain.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Yes. Bringing up muscles, I mean, in our general population, we start losing 8% of our muscle mass for every decade that we live. We naturally become weak without exercising. But then you add the complications of diabetes and blood flow issues onto that, and that number is going to go higher. People often do not think about exercising their pelvic floor, but for men and women, their pelvic floor is basically a set of muscles holding everything in place. You do not think about it until, all of a sudden, you are having control issues and having problems holding in urine or holding in stool. But I want to remind people: start doing your kegel exercises right away. Keep those muscles strong. If it has been a while and you have already experienced those issues, you can always strengthen those muscles. If it is not just goals, it might just be sitting in a chair and taking a ball and putting it between your knees and squeezing your knees together or rolling up a towel. Squeezing the knees together can actually trigger the pelvic floor.

Nowadays, you can find pelvic physical therapists almost everywhere. Sometimes that is a great place to start because they can get you to the point where the muscles are strong enough that you can do the exercises on your own. Once we strengthen those muscles, it helps us hold urine, gas, and stool easier because those are the muscles that we use to hold those areas. Building those muscles up, and even in women, if those muscles are weak, we can actually start getting a drooping of the organs. In women, you can get what is called a prolapse. That is where the bladder starts to droop, the uterus starts to droop, or the rectum starts to droop. Most women do not know what is happening. All of a sudden, they might just one day look at or feel a bulge down there. Often, women’s first thought is, What is this bulge? Do I have cancer? I will tell you, most likely, that it is a prolapse. Since 50 to 80% of the population can experience prolapse at some point in their lives, depending on the studies that we are looking at, do not just start doing your exercises; ignore them. Get to a gynecologist, urologist, or urogynecologist and make sure that is exactly what it is. But we can even strengthen our muscles. We can actually reverse some of that support problem in the pelvis. 

I know I get focused on the pelvis because that is my specialty. But our pelvis can be the keystone of our body. If our pelvic muscles are weak, this can add to issues with balance because of our hips. Our legs are coming into our hips, and then our hips are in our pelvis, which is supporting our spine, especially with diabetics. If you get to the point with diabetes where you start to lose nerve function and maybe the feeling in your feet is not so good, that can affect balance. Then, if you add these weakened muscles on top, it can affect balance. Strengthening your pelvic floor is going to help you with your balance and, therefore, be something else to help protect you from falls.

Beverly Yates, ND

It makes sense to point that out. Man, these things are all connected. This is so far from an interview. One thing leads to another; you improve this area, and all these other things get better. 

Betsy Greenleaf, DO, FACOOG (Distinguished)

It is really amazing how the body works.

Beverly Yates, ND

Now there are so many reasons for self-care, and making this the focus with clarity about what is going to make the difference so that you can live long and live well and not suffer as you get older, tell me, Dr. Greenleaf, what are your thoughts on this? Do you feel a lot of people are set up to just think I am getting older and just accept things? Do they not have to just accept?

Betsy Greenleaf, DO, FACOOG (Distinguished)

I think it is starting to change, but I still see that, for the most part, that is unfortunately what people think. Fortunately, I think that is a little bit of traditional Western medicine because we have either done a study recently that said the average doctor has 15 minutes to spend with their patient, and the average patient comes to them with about seven concerns. When you think about it, your main concern is going to be addressed, but all those other ones take up less and less time. I think that when it comes to education, unfortunately, because of the constraints that are placed on doctors in the traditional system, they are not able to get the education that they need. But people like you, who are doing amazing summits like this, are now helping to spread more information. I think patients are now starting to say, Wait a minute, I do not need to just go to my doctor and try to rush through and get the information. There are other sources, including the amazing Dr. Beverly Yates, other summits, online sources, and different programs and courses. I think that people are starting to take their health into their own hands, which is wonderful.

Beverly Yates, ND

Thank you so much for your kind words. I am always an advocate of people being responsible for their own health, taking charge, getting great information, and making sure whoever they work with is qualified to help them. Figuring out what really works for them, because one size fits all does not work for anything. It does not work for health. It does not work for clothes. 

Betsy Greenleaf, DO, FACOOG (Distinguished)

Exactly. I hear you. I totally agree with that.

Beverly Yates, ND

As we wrap up our session, Dr. Greenleaf, you have uncovered so many gems here. I am just thrilled that this is a great interview. Is there any one thing you would like people to remember before we wrap this episode?

Betsy Greenleaf, DO, FACOOG (Distinguished)

I just really want people to realize that there are so many options. Just because it is something that is common does not mean that you have to live with it. There are options, and if you are not getting the answers that you want from your doctor, guess what? There is no reason why you should not find another one. Find one that works with you and that you feel you can talk to. Unfortunately, especially I have seen this amongst my parents. Well, I do not want to hurt the doctor’s feelings; forget about the doctor’s feelings. What about your feelings? Go find the person who is going to listen to you, and you will feel comfortable with the person you think you are getting the answers from. Sometimes it takes more than one set of eyes to come to a solution. The more, the merrier. Make it a party.

Beverly Yates, ND

Exactly right. Sometimes you do need more than one set of eyes. More than one heart or brain on a problem. You can put the whole thing together, as can the people here.

Tell me what your thoughts are about this. Have you noticed that sometimes people are in different phases of their problems, so they present a little differently? Everybody gets to see a little different part of the puzzle.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Exactly. No, I totally agree with that. Also, I have seen patients come to me who are in their 80s and say, Well, I have been doing this for how many years? There is nothing I can do now. There is always something you can do. Honestly, can we reverse you to the way you were before you had diabetes? Probably not, but we can get you pretty darn close. At any age, it does not mean you have to give up and throw in the towel. There is always something you can do to make the situation better.

Beverly Yates, ND

 Yes. Absolutely.

Betsy Greenleaf, DO, FACOOG (Distinguished)

Especially with all the new technologies and things that are coming out. There is always something. Never stop searching for answers.

Beverly Yates, ND

That is a great note to end on. Folks, always stay hopeful. Make sure you hold the people around. You are supposed to hold yourself accountable. Dr. Greenleaf is making it really clear that there is always something you can do to make the situation better. Thank you so much. It is a fantastic episode. Friends, as I said before, please share this summit with other people that you know who are looking for better health, who want great information, and who are looking for options and ideas. They can find inspiration in all the wonderful episodes from all of our speakers. Thank you so much for this episode.