Recover Your Confidence From Prolapse

Introduction and guest background 0:00

All right. Welcome back, everybody, for another great session of the solving sexual dysfunction summit. We have Dr. Tabatha Barber with here to us here today. I'm so excited to talk with Dr. Tabatha. Thank you, Dr. Tabatha, for being with us. Oh, I'm so excited for this conversation. It's much needed. So thank you for all you're doing, Dr. Betsy. You know, before we get into it, I love I love everybody telling their back story because I just find it so fascinating. How did you end up in the field that you're in?

Oh, my goodness. Yeah. I have a pain to purpose story, so I'm essentially a high school dropout. I got pregnant in 11th grade. I dropped out after that to take care of my baby. But I had a very traumatic delivery and a lot of things were done to me. Nothing was explained. There was no informed consent, right? I had been miserable, crying, begging for a C-section after 3 hours of pushing. And when the doctor came in, I thought I was finally going to have relief. Like, you know, I was like, oh, thank you, Lord.

And he came in, put me up in stirrups. And I experienced the most excruciating pain of my entire life. And that day changed me because, unfortunately, he used forceps to deliver. My daughter only was sunny side up, so she was facing the ceiling instead of the floor. She's been a stargazer ever since, but he taught me fourth degree all the way through my act and turns out he was a family practice doctor and he did not do a very good job putting me back together. So I have had lifelong issues and, you know, embarrassing things that I've struggled with that most people would not even admit to, like the fact that I have to push on my vagina to have a bowel movement and that I've had painful intercourse and issues my whole life because of that, starting at 17 years old.

So it was very traumatic and I had a come to Jesus moment and God made it clear that I needed to figure my life out for myself and my daughter and prevent those things from happening to other women that had, you know, that I had suffered through. So it's been this long pain to purpose journey and out of it. I've just come to understand that we need to share our stories and our uncomfortable, embarrassing moments so that we can help other women not go through what we went through. Right. And that's such a such a beautiful story.

What prolapse is and why it happens 2:53

And to think that, first of all, I just think it's amazing because unfortunately so many people in the United States would take something like that and just get stuck in that victim mentality. Poor me. And you actually took it and was like, I'm going to become a doctor. Like. You know, that's that's just amazing. And then that really ties into what we're talking about today, which is prolapse. And not everybody knows what that is, but they say 50%. And I think that's conservative, but 50% of all women are going to have a prolapse at some point in their lives.

And I really think that number is a lot higher. But can you explain what is a prolapse? Yeah, I think that this needs to be talked about more. So I'm really excited to have this conversation because women don't understand what's going on down there. We don't look a lot of times we don't feel, you know, I remember getting a call in the office one day in the triaged, nurse said There is a patient freaking out because she feels a mass in her vagina. And literally she was feeling her cervix. And it's just we don't know.

We don't teach people this. We don't talk about this in sex ed. So the cervix does feel like a little donut, you know, up inside of your vagina. And it should be up. There are a few inches, 6 to 8 inches. You know, you should have room, you know, for penetration and intercourse. But a lot of times our organs start to come down. We lose the supportive structures inside our pelvis that are kind of suspending the uterus, the tubes and the ovaries up and out. And then when we think about the vagina, we have like a front and a back and a top and sides.

And so in front of the vagina is kind of where our bladder lives. And the back is where the rectum lives. The top is where the uterus and cervix live. In the sides is more connective tissue. You know, we have lots of little strong muscles. You know, this you're your gynecologists, connective tissue, ligaments, all kinds of things working together to to keep everything up in place. But unfortunately, gravity takes its toll. Carrying children takes its toll, carrying extra weight, things that increase our pelvic pressure like our cell ring.

The new thing is like lift heavy. You're not strong and sexy after 40 unless you lift heavy weights. And unfortunately, there's a lot of women who are now experiencing prolapse because of this trend to lift heavy weights every time you like, hold your breath and push, you're pushing those organs down. I've had women call me freaking out like, Oh my gosh, something's coming out of my vagina. I felt a bulge in the shower. What the heck is going on? And it's because that's too much pressure for those ligaments.

You know? And as we age, we lose some of our connective supportive tissue. Our collagen starts to break down. You know, we see this on our skin. Our skin gets thinner and creepier. All of a sudden we look like, oh, my gosh, why am I so old? And you're, like, pushing your face up. The same things happening in the vagina. Things are falling down. And so that is prolapse. And prolapse can be defined in many different ways, as, you know. You know, it's I'm sitting here laughing only because my colleagues all made fun of me, because I know too much as a uro gynecologist.

And I thought I was being smart. And so when it came time for me to have my kids, I scheduled my own elective C-section. No, I didn't do it on myself, but I had made arrangements with one of my colleagues and people were like, I didn't know you could do that. Well, wouldn't you know, I still ended up with a prolapse and and still and had to get it fixed and everything. And my colleagues love to point out that it doesn't you don't have to have a baby vaginally, just the way to pregnancy or even like I've had women over the years who've never had they've never had children or never been pregnant and have developed these things.

Absolutely. And I think part of it is the weight lifting more than anything and the terrible diet. You know, we're all eating the standard American diet and we're just not getting the protein necessary for our ligaments and muscles to repair and regenerate, you know? So that's a big deal. And I did the same thing. I scheduled my second C-section when I was a senior resident, and I thought I was going to save myself because I already had a wreck to seal, which we can talk to, but talk about how. But it didn't help it.

It just caused my son to have issues because he was born without the vaginal microbiome, like saving him. And he had chronic allergies and gut issues and all these other things. So I just traded one problem for another, unfortunately, and I'm so glad that that trend is over. It was like a big popular trend in the early 2000s. I think it started in Brazil, but thank goodness that's over. So yeah. And that's a good point because I if I knew about the microbiome back then, I wouldn't have done it. You know, and it's one thing if you have to have it for emergency reasons, but to do it electively, it doesn't save a darn thing.

So it does not. So yeah, I think, you know, if you are feeling a bulge, it's important to get it figured out. And what I came to understand is that not all gynecologists are trained the same. You know this a lot of gynecologists were trained in the era where laparoscopy was just getting popular. And so vaginal surgery and vaginal examination and pestering and things really fell by the wayside. And so luckily I learned a lot of vaginal surgery. So it was really important to me to understand prolapse.

And I got good at evaluating with the exam of like, is it your bladder coming down? Is it the entire uterus? Is it the rectum?

Recognizing symptoms and getting evaluated 9:08

What is happening? And I got to the point where I was doing robotic sacral cultural practices multiple times a week because so many women were struggling with this and no one had ever talked to them. So when I asked them, it was like, oh, my gosh, yes, yes. So I like I quickly created a practice where I was doing pessary every week and prolapse surgery and all of these things. But it's because we're not having that conversation. And I just don't want women to end up like the one lady I saw in residency.

It was like an emergency console in the ICU because they thought she had cancer and literally it was her uterus between her legs. And she was like, No, honey, I just push it back up. I know what to do. And that was like the saddest moment ever realizing women just struggle in silence. We don't even ask for help. Something that drastic. But there is help, I promise. You might have to go through a few gynecologists to find the right one to help you, but there is help for this. So that's why I was going to ask you, like, what should somebody do if all of a sudden they feel something bulging or feel something heavy?

Because I know too often people's mind goes, oh, my God, is a tumor. I have cancer. And they they panic. And then or they go the opposite way and they're like, I'm just going to ignore it and I'll go away. Like, they go into denial. Like, I don't want to know what it is, I don't know what it is, but I don't want to know. So those are very common scenarios. And the best thing to do is to see if you're a you in knows about prolapse and can do an exam to evaluate you. And you have to understand that those that prolapse can be dynamic.

So sometimes if you're doing physical activities or you have a chronic cough because you're sick or something, something can push down in Baldo but it can go back up. So when you're laying on an exam table, nothing might be very obvious to them. So just kind of be aware of that. But I would say, you know, it's good to be examined by the same person every year because then they kind of can see any changes that might be happening. And for a lot of women, they're never told like, oh, you have outright prolapse, but all of a sudden they can't empty their bladder completely because now the urine has to go uphill over the bump or they're leaking and they can't hold it leaking with cap, coughing and sneezing.

Sometimes they do have constipation and bowel, you know, stool is not evacuating properly or a change in their stool or sex is painful. You know, if you've had a great sex life and things have been fine and now you're feeling like something's in the way, he's pushing on something. Something hurts. That's a signal that, yeah, you might be experiencing some prolapse. I know a lot of patients end up going, like when they find out they have a prolapse, they get nervous to let their partner know or they're afraid to have sex because they're afraid to ruin it or make it worse.

Right. Right. And that's just really not the case. It might be uncomfortable, but you're not going to hurt your or hurt yourself. Like damage wise, you might be uncomfortable and sometimes you got to push it back up a little bit and try to get into that relaxed state so those organs can go back to where they are. And some women need to have a bowel movement before intercourse because they're afraid they're going to have an accident. They're going to actually feel like they're having a bowel movement.

If you have that issue, you might have a rectus seal, meaning your rectums kind of pouting into the vagina in the back and it can look like a little bulge. And if you push on it, it might feel like the urgency to have a bowel movement, that's what it feels like. So if intercourse feels like, Oh my gosh, I'm going to have a ball movement, yeah, you might have a rectal seal or I'm going to pee myself. You know, you might have a sister seal, which is the bladder coming down. And so I think these are important things for patients to realize because they might just be using the words, I'm uncomfortable with sex and the doctor isn't getting it.

Like what? You know? Yeah, I like how you brought up. Not everybody looks, you know, knows how to look for these things because I know I'm my regular ob gyn and it depends on where you get trained. My regular OBGYN trained before I did your rocking. The. Vagina was just the pathway to look at the cervix. So everybody looked at the vagina. Everybody just put them in speculum, got your pap smear to the cervix, got the pap smear and then got out. And it wasn't until I went to Europe again and did a different training, but it sounds like you had great training.

But like I went in and I was like, Wait a minute, there's a whole world in here. Like, there's a lot going on. There's other things that you should be looking at and feeling. And, you know. That's an important point because the speculum pushes the cyst to seal in the rectum, seal away so you don't see it with a speculum. You have to remove the speculum. You have to take the speculum apart. You have to put it in different ways. You have to use your fingers to feel those tissues between the rectum and the vagina and the bladder and such.

So it is a different exam. It is not a pap smear. It's not a speculum in, speculum out. And especially if women notice that their gynecologists has trouble getting their speculum in, like that's really uncomfortable or you got to move weird or you know, they're like, I can't find the cervix. A lot of times that's a prolapse issue. You know? And I'm thinking, too, when it comes to like these exams, like you were saying, too, when when people lay down, it goes back up. And so sometimes and which is actually sometimes good when it comes for patients, because that may be one of the signs that they're having problems because they're like, Oh, you know, my discomfort isn't as bad in the morning, but as the day goes on and I'm on my feet.

So like if you're seeing your gynecologist at like 9:00 in the morning,

Treatment options: pessaries and pelvic floor therapy 15:20

your exam might be totally different than if you saw them at like 4:00 in the afternoon. Yeah, that's a telltale sign. A gynecologist who's asking you these activity type questions knows about prolapse. They're going to ask you if it's different with activities. They're going to ask you to cough or push, bear down during the exam to see if they can elicit that movement of your organs and that relaxation. So those are all really important points. And you know, I inherited a very mature practice. The gentleman that I replaced was retiring at 74.

Oh, my goodness. And so I had a lot of older women. He had like delivered all their babies, taken them through menopause. And so I got all kinds of prolapse patients and I became great at Desiree's. And I would be remiss if I didn't mention that series because they're such an awesome tool to avoid surgery. And I believe they sometimes reverse or stop prolapse from worsening because you're no longer having that stretch and that pull on the connective tissue in the muscles. Essentially, you know, this it's a silicone device or some other material that is comes in different shapes and we fit it as a gynecologist.

We figure out which size sits in your vagina properly and pushes up your bladder or your uterus, sometimes the rectum, but not as as well. And we find out what one fits for you, and then you wear it. And women who are sexually active, you can remove this for intercourse, clean it off, pop it back in. And that could be a way to prevent yourself from having surgery or from the prolapse getting worse. And you can keep exercise rising and keep enjoying life and all these great things. You know, older women, if you're not sexually active, you can leave it in and have the gynecologist take it out and clean it.

So I just love that option and I wish that more gynecologists were trained in that option still, because once you jump to surgery, we know that the relapse rate is, what, 30 plus percent within a couple years? So you're usually signing up for recurring surgeries every 3 to 5 years because we're relying on your own tissue, which is already weak, and we're trying to use it to strengthen that area. And it can only take so much. So I just I would encourage women, if you're struggling with this, find someone who does passphrase, who understands prolapse, because you shouldn't have to give up sex and exercise and all that good stuff just because you're having this issue.

You know, I, I think it's fascinating with the idea of passages and they've been around basically since the dawn of time, like in ancient Egypt, they were using like the potato with granite and stones, which I don't advise. You know, there's there's that story about somebody using a potato and it like grew into their you know, we don't. Recommend that. Don't do the like. And actually, I have a friend who just started a new company I'm trying to find out more about. It sounds fascinating. They're actually using some kind of technology to individually fit passages for people.

So and then they're like 3D printed. So that would be so awesome. Yeah. So it's just coming around. So it's interesting to see where they're going to go with that because I'm like, Yeah, you know what? Even the past revealed, the actual devices haven't been updated and I don't know how long. Yeah, they've been. Pretty much the same forever. You know, the material is better, so it's not breaking down and causing infections and things like that. But the shapes and sizes haven't changed a lot. You know, I know sometimes people get worried when they have one of these things because it starts drooping and drooping that they're afraid that they're going to be walking down the street and they're like, vagina is going to fall out on the floor.

So yes, no, it's not going to detach. It's still going to be attached to you. And you like I said, you can push it back up into your body. Sometimes you have to do some deep breathing to relax yourself. That's a very extreme case, I would say. I only saw about a handful of times in my practice, but you can definitely feel that cervix at the opening in the vagina for a lot of women or the bladder or the rectum poking out like that. And so you want to learn how to do pelvic floor exercises properly.

Bad kegels make it worse. I know where I live. We have great pelvic physical therapists and they're becoming more common across the country so you can find yourself a pelvic floor physical therapist. They can work wonders on strengthening your pelvic floor and those connective tissues so that if you do have a prolapse starting, you can often stop it or reverse it. You know? And that's something that's so frustrating about the American medical system, is that when women are giving birth, that's a big trauma on the body.

I mean, obviously, you know, and then you're just sent home to be like, okay, you know, have a nice life with your kid where in. Europe. There. And in France in particular, every woman that gives birth automatically goes through physical therapy. And I'm like, Why are we doing that here? I mean, like if I had my niece or if I had surgery on my knee, I'd be going to have like physical therapy. Why not? If something's happening to the vagina. We're still second class citizens. Unfortunately, I think that would have changed a lot for me in my life.

It would have changed my relationship with my husband. It would have changed a lot of things. And it's sad. It really is. So you have to advocate for yourself. I have to ask you can you cannot put up with these problems. You just know that there are solutions, there is help out there. But you have to advocate for yourself. You know what other things do you find that people tend to get worried about with prolapse and just kind of like going through my catalog of I think, you know, one of the things that people think about is if I don't fix it, is it going to get worse?

Or like, what's going to happen if I leave it alone. I would say that from my experience, it usually does get worse because you need to be proactive. You need to change your diet and start eating more protein rich foods, getting those amino acids in to help heal your muscles and your collagen adding extra collagen supplementation and change up maybe how you're working out. Or do you have a chronic cough from reflux or a lung issue that you need to take care of? And so all of those things do you have extra weight you need to release?

And that's a whole nother topic, right? Like the doctor says, just lose weight. Okay. Well, if we could have done that, we would have already. Like, thanks for the great advice. You're a genius. But it is true that carrying extra weight is, you know, related to pelvic prolapse.

Surgery, mesh, and when to consider intervention 22:48

So if you can do some functional medicine work and get to the root cause of why you can't release that extra weight that you could be potentially be carrying, that can help a ton, especially with bladder stuff. So some people, they get afraid. They get afraid that it's going to cause cancer or things like that. And it's really not going to it's just an annoying it's it's uncomfortable. It's like you said, it's been a problem since the beginning of time for women. And I always say unfortunately nature doesn't care that let our vagina stay where they're supposed to be.

Like the key is to get the baby out. So we have breakaway zones. Unfortunately, and then, you know, and then certain things that we do during childbirth can sometimes aggravate that or sometimes it's just the luck of the draw. So some and you know, you just made me think of something I do want to say, like having a hysterectomy does not preclude you from getting a prolapse. So removing those organs, you can't hopefully you don't want to remove the bladder in the rectum, but removing the uterus doesn't prevent prolapse.

And often we see vaginal vault prolapse. So after we remove the uterus and the cervix, we at the top of the vagina where the cervix was, we close that shot. We call that the vaginal cuff. And so your vagina turns into kind of like a sac. It's just like a little tunnel with a closed up top. But that top can fall down and that can actually come out of the vagina and you can have vaginal vault prolapse. And that is pretty darn common from hysterectomy because a lot of gynecologists are not trained in how to protect those ligaments and not destroy them during the hysterectomy or to support them and tack them up afterward.

So I would say I probably saw the most prolapse post hysterectomy from other gynecologists doing hysterectomy. So then they would come to me with the prolapse. And so just keep that in mind and I think we trained at the same time where mesh was all the rage, right? Oh, yes. I came out right when it was we were putting in mesh left and right and now I go, Oh my God, why were we doing that? So we were. Doing it on like a 35 and 40 year olds with grade one and two prolapse like didn't should not have had mesh, but it was all the rage and everybody's as the greatest.

Like, you'll never have to have surgery again. Mesh as this is going to fix everything. Everything. Because there was little anchors on these pieces of mesh that would anchor in to your pelvic bones. And so, yeah, that's a great idea that it's going to be like a hammock. It's going to hold everything up. It's never going to fail. We didn't account for all the erosion and things like it would grow and put holes in our bladder, in our vaginal walls and in our rectum. And if people weren't trained properly, the anchors would be in the wrong places and cause, you know, artery injuries and nerve injuries with chronic pain.

So unfortunate. Atley Women are guinea pigs in the medical system. Let's just be honest and I still apologize to this day that I was part of that. But once you know better, you do better. Right? We didn't know we were residents. We were this is how we were trained. And then all the backlash came after that. And it's not to say that mesh isn't useful and necessary sometimes, but it's usually after you've failed a traditional surgery and you have tried other means. Like I would use mesh as a last resort and I would make sure that your vagina is very healthy.

You got a good vaginal microbiome, you got good estrogen replacement to keep that vaginal tissue healthy so that the mesh doesn't have erosion and doesn't show through because then you're going to have major chronic pain with intercourse and all sorts of issues. So yeah, that was quite the yeah. You know, I agree because I train during that, that time period too and I go, oh my gosh, like, you know, it's like what we know now. But I think near the end of my surgical career, I before I retired, they, I was like the surgeon who didn't do surgery because I started getting to the point like, why are we doing surgery when there's all these risks?

Like what's like what's the worst thing that can happen? So I always tell people and this is what I would tell my patients, the time to have surgery is when it bothers you enough, whether that's physically or mentally, that you're willing to take on the risks of surgery and that you haven't tried everything else first. So like surgery should not be the first go to it should be like the last, last thing. And, you know, not that I want to bash traditional medicine, but I am so many people have heard me tell this story.

Before I retired, I was working at a hospital where we had a guy that he was dressed right out of fellowship and our salaries were based on how many points we we got in in every procedure, had a point value. And I came into work one day and this newly graduated fellowship trained surgeon is in our office, and he's seen his patients. And I see him with the box and I'm like, What are you doing? It's like the book with all the hours relative, the code, the relative value units, and he was deciding on what surgery to do on somebody based on how many points he was going to get.

So that's something, you know, not that you know, this is a small you know, as much as we kind of bash sometimes on on traditional medicine, that's a small portion of the medical field. But I always tell people, you go to a surgeon, they're going to tell you to do surgery. So absolutely, like you're speaking the truth right now is absolutely the truth. And as much as I am an advocate for women and I went into this field to help women, I loved being a surgeon and I got caught up in it just as much as a lot of other people.

Thankfully, I never completely lost my mind. But you are right that a lot of times those financial incentives drive surgeons decisions, and gynecologists are surgeons. We are not hormone experts. I had to go to extra schooling through functional medicine for him. All these things to learn how to handle hormones and take care of women's functional health. You know, I was a surgeon. I did hysterectomy and prolapse, repairs and colposcopy and stuff, C-sections and delivered babies. I used my hands and so were just looking to the wrong people and we're expecting the wrong options from them, essentially.

So just know that. Yeah, I really just say, you know, the biggest questions to ask is do I really need this? And what what would happen if I don't do it? You know, if it's long as you, you know, you ask and then you have to ask yourself, like, how much does this bother you? And it could be it could be mentally bothering you. It could bother you to the point where, like, I'm freaked out that my vagina is hanging out. Yeah. I've had ladies that have come in whose vagina is inside out, like you said, like a sack.

And they've been sent by their gynecologists. And I checked as long as there wasn't any other medical problems. We go. Is it bothering you on that go now? I just pushed up when it bothered me. All right, then. Let's come back in six months and I'll just keep an eye on it. As long as nothing else is happening and it's not affecting your kidneys or your bladder, you can leave it alone.

Closing advice and where to learn more 30:48

So absolutely. Absolutely. And that's where the pelvic PT and the pessary and all the other options come in so handy. You know, like surgery is incredible. I've saved lives, I've saved babies, things like that, you know, like people from bleeding to death. It's. It's required sometimes I get it. But surgeons do like to do surgery, so just know that you might not actually need it as the major menses thing. So is there anything else that I didn't ask you about prolapse that you think is important for us to know?

Oh, I think just be wary of the signs and symptoms of, you know, it might be more bladder related, more bowel movement related, you know, especially if things have changed for you. If you're going along and you've had normal bowel movements and a healthy bladder and a healthy sex life, and then it's like, Oh, now I'm constipated. Or My stools look like pencils. They're thin and long or Yeah, I'm not enjoying intercourse. It's feeling uncomfortable. I can only do certain positions, that type of thing.

Then sounds like something's changed and you need to get it checked out for sure. Well, that's this has been amazing. Thank you so much, Dr. Tabatha, for talking with us. Where can people find out more information about you? Oh, it's so easy, drtabatha.com, D R T A B A T H A.com All right, everybody, go make sure you check out Dr. Tabatha's site and stick around because we have more great sessions coming up.