Topic of the week at Full Circle.......post menopausal women in their 60s, 70s and 80s
working hard, busy harvesting in this agricultural valley and frustrated! 
In pain! 
Pushing too hard! 
Not coping, not sleeping, not restoring.

This blog is a loving reminder that after our bodies are no longer supported by estrogen, we aren't as physically strong as we once were BUT even moreso, our endurance will have waned somewhat. 

There are some habits that will bring us joy in doing those meaningful work, rest and play. 

Here are my suggestions:

1.  Jot down your list in pencil, then prioritize.  What 3 job actually need doing today?  Which ones could wait until tomorrow or tomorrow's tomorrow?

2.  Know when you have the most physical, emotional and relational energy.  Match the job to the time with some cleverness.

3.  Stay ahead of your endurance dips.  Plan a wise, intentional, constructive 15 minute rest mid or late morning and repeat that in the afternoon.  Don't wait until you're at the over and out stage!  You'll know that you're    becoming brilliant at this when you feel pretty lively in the early evening and have the energy to enjoy some fresh activities when the sun is going down.

4.  Support your sleep.  Get boringly attentive to the same time, the same place, the same room, fresh air, warm bed, comfortable sleeping duds, no tech in the room (use a non-cellphone alarm)......think of when you were desperately trying to get your babes to bed and treat yourself with the same brilliant sleep support.

5.  If you enjoy a daily glass of wine, have it at lunch rather than dinner or evening.  Wine can create a pancreas-induced awakening in the wee hours. 

6.  Awaken with energy......you'll know that you're doing all of the above well when you awaken with energy, not ache and pain and dread.

7.  Go for a walk.  Those big muscles that move you through space (your gluts) are made for the job.  Enjoy a walk daily.  Breathe in deeply and stand tall at each telephone pole that you pass, letting your arms swing with each step.  Enjoy the freedom of movement, the place that we get to live and the beauty of the onset of autumn.

8.  Make time for something that you truly enjoy.  Knitting?  Reading?  T'ai Chi?  A phonecall with someone that you miss?  An email or an old fashioned letter?

9.  Most Importantly - Know your priorities, moderate your expectations and have respect for your age and stage.  You're one of the lucky ones who is here with all the wisdom that the years have brought.  Some self-compassion and self-care (not just self-soothing.....a pedicure and manicure are wonderful, but self care is the practice of employing daily habits that provide you with optimum health and joy) go a long way. 

Take care of yourself.

As the days are shortening, the evenings are having a sense of chill and we're harvesting tomatoes and peppers.....we begin to see the glimmers of summer's end.  "Unprecedented" describes the summer of 2020 in every way.  It's been a summer of constant change, resiliency developed, losses noted and a deeper sense of home for so many of us.  No traveling?  You've stayed home, found your place, your town, your city.  Not visiting restaurants?  You've cooked at home more, enjoyed takeout, eating in the park, shared meals with family more often.  Not going to the gym, pool or ice rink?  You've walked, biked or just rested.  Or???

Interesting times.  This is a short blog, a simple nudge to check in and take care of yourself.  Check in with the human in the mirror.  Notice how you're feeling, how you're thinking, how your body is responding to today and all it has brought to you.  You don't have to begin to journal or meditate.   Checking in with your one and only home, the body you inhabit is a gift to yourself.

Our body "keeps the score", noticing all the experiences, interactions, life habits that we experience every day.  Are you holding tension in your shoulders?  neck?  pelvic floor?  hips?  feet?  What would it feel like to let that go?  Maybe tighten up your tight area more....more..........more.  Then release!  Is that different?  Is your posture restfully letting gravity pass through you when you're standing up?  Or are you a "bum tucker", "chin poker" or "sloucher"?  Begin at your sit bones (in standing).....rock them back and forth with your breath, then let them release just when they're pointing straight to the ground.  Feel them!  They're an amazing pair of dense, thick, strong bone that is the centre of your pelvic floor and your sitting destination in the chair.  Hold that.  Then lift your sternum (breast bone) up to the sky.  You'll feel your braband lift off your front ribs, your mid spine activate right where your bra does up, your shoulders rock back and settle and feel an urge to take a brilliant, nutritious deep breath!  Hold that.  Finally, tuck in your chin towards the back of your head, not tipping forward, simply making a wee double chin.  You might feel an urge to clear your throat or swallow.  Hold that.  Now notice how that feels.  Look forward.  Feel tall and strong.  Really Strong!!!  Gravity is passing directly through you, through the curves of your spine that provide you with spring-like responses to movement, through your strong, dense cortical bone and your balance will be dynamic and spunky.

There is no perfect posture.  Each of us is built differently, has had different experiences in life and does different things with our body each day.  But you can enjoy ease in your body by taking time to check in and find ease-filled, gravity-enhanced, respiration-supported posture and movement through your day.

When you notice that life feels heavy, that losses feel cumulative and "life as it was" feels distant, find your strong posture, your gravity defying self.  Breathe fully.  Balance well,  Stand and walk with ease.

The second chapter on men's pelvic stories is a more specific look at how men (and those who love them) can work through pelvic challenges, focusing on prostate cancer, surgery and treatment.  The first chapter talked about the pelvic problems that a man may face.  The good news is that with pelvic physiotherapy and a solid commitment to follow through with the work at home both before and after surgery and treatment, complete resolution of both leakage and impotence is possible.  Each man will have varying severity and duration of these physical side effects and they can lead to a much reduced quality of life.  You can rewrite your story with help.

The protocol that is described here leans heavily on the brilliant work of Jo Milios in Australia, a pelvic physio devoted to men's pelvic health and aided by over 3000 men who have had radical prostatectomies.  Men who followed this protocol had much less leakage, much reduced duration of leakage and a much improved quality of life throughout their recovery time.  Even more convincing is the statistic that 1 in 6 men had no leakage whatsoever!

For 4 - 6 weeks prior to surgery and resuming immediately after surgery, men are taught the following protocol:  six times daily, in a standing position, two exercises are performed.  The first is 10 fast twitch (or speed 'ems) maximal (full on!) contractions and releases.  These are followed by 10 slow twitch (endurance building or hold 'ems) contractions, holding each for 10 seconds with a 10 second relaxation time between each contraction.  It's important to find "the right muscles".  Try this:  squeeze the front passage as if you're stopping the flow of urine, then lift your testes and retract the penis.  Doing these exercises in standing is important as this is the position in which most men leak.  With your pelvic physio, you'll learn awareness of which muscles activate correctly, then how to release fully and more!  The importance of "pre-hab" or beginning training prior to surgery can't be reinforced enough.  The time between biopsy/diagnosis and surgery is a time to begin learning about your pelvic function, strengthening and releasing.  Bladder control (voiding with control and fully 6 - 8 x daily or learning to do so) and a happy bowel really make a difference as you head into the choppy waters of surgery and treatment.  Jo's research has shown that men respond very well to the improved physical control of their waterworks and sexual function with this help, but additionally they are emotionally and relationally so much stronger!  Her goal is to improve the quality of life for all undergoing prostate cancer diagnosis, surgery and treatment.

Let's get specific....one appointment for assessment/training is sufficient to help you begin.  Palpation can be done externally in most cases.  Your important three muscles that control your urine, the trio that you need to learn to turn on and off and strengthen are called the external urethral sphincter + bulbocavernosus + puborectalis.  Sometimes that pesky external anal sphincter gets dominant and you need to learn to teach it to quiet down.  Once you've found these muscles, you'll move onto working in synergies, becoming powerful (for coughing and sneezing), strong (for sit to stand and lifting), having endurance (for standing and walking), improving the quality of contraction/lifting of the pelvic floor as well as improving release/relaxation in order to support the next contraction.

The toughest bit?  Fatigue.  Standing upright will fatigue the system and that fatigue may worsen as the day progresses, causing leakage to occur.  Many men will have overactive muscles that need to learn to release and NOT exercise at first (called pelvic downtraining), some men will vary

When I write about women's health, oncology (cancer related) and pelvic physio, it's a logical to assume that it's only women that we pelvic physios assess, treat and talk about.  This is the first in a series of articles that will introduce you to the challenges that men face in their pelvic region, despite "being absolutely mortified to be discussing their private parts" (to quote Dr. Jo Milios, our lead teacher, a brilliant physio who had set up a non-profit organization in 2012 in Australia called PROST! Exercise for Prostate Cancer Inc.).  Her passion is to educate all of us so that the everyday man on the street has better health outcomes and a much longer life.

Pelvic physiotherapy for men addresses loss of function in the pelvic region including prostate cancer pre-hab (prior to surgery and other treatments) and rehab, pelvic floor muscle dysfunction, urinary incontinence, painful urination, recurrent bladder infections, urinary frequency, bowel dysfunction, erectile dysfunction, chronic pelvic pain syndrome and Peyronie's Disease (a crooked or bent penis).

Let's begin with the prostate.  The prostate gland is a walnut sized donut shaped gland found right under the bladder and wrapped around the urethra (urine tube).  Its job is to produce most of the fluid that makes up semen.  The prostate can become inflamed (prostatitis, acute or nonbacterial) or enlarged (benign prostatic hyperplasia).  Enlargement of the prostate doesn't mean it's cancerous and is usually noticed after age 40 during a regular doctor's visit.  Prostate cancer is the most common cancer in North America and accounts for 11% of all cancer diagnoses in BC men; 1 in 9 males is expected to develop prostate cancer in their lifetime with 89% of them being over the age of 60 when they are diagnosed.  There are some well known correlations (not causes) that may raise a man's risk of developing prostate cancer, including aging, family history, high levels of testosterone, being overweight, not exercising regularly and a poor diet.  Large studies have shown that there is no correlation between having a vasectomy and prostate cancer.  Yet again, Grandma's sage advice to exercise regularly, eat real good and maintain a healthy weight (for all cancers!) are actions that you can take to reduce your risk of developing prostate cancer.  Your doctor (GP or urologist) or nurse practitioner may do a DRE (digital rectal examination) to palpate your prostate or you may have a PSA (blood test) to measure how much of a specific antigen is in your system.  If you notice changes in your urination (stuttering flow, slow stream, painful, frequent, dribbling/double voiding, feeling the urge to bear down to start or finish, urge or loss of control, increased night time voiding or blood in your urine and/or painful ejaculation), please tell your doctor.  Even though it's difficult or embarrassing to open up these conversations, your healthcare professional will want to know, will have had these conversations before and will make you comfortable sharing your story.  Tell them!

We pelvic physios become involved with men going through prostate surgery because most men (99%) will experience incontinence and erectile dysfunction.  One of the prostate's secondary jobs it to support the bladder and to give neurological support of continence through the autonomic (involuntary) nervous system.  The Cavernosal Nerves, responsible for erections, are wrapped around the prostate and they're usually damaged or removed in the process of the surgery.  Each man will have varying degrees or severity and/or duration of physical side-effects of the surgery but please know that each man will generally improve over time.  With pelvic pre-hab and rehab, complete resolution of both continence and sexual function is possible.  It's all about restoring wonderful function and quality of life while reducing anxiety and depression, penile fibrosis and shrinkage and stopping the development of Peyronie's disease.

Most importantly, men and partners who love men, talk with your doc if your experiencing pelvic dysfunction.  In part 2 of this series, I'll share Dr. Milios' well researched brilliance after seeing >3000 men with radical prostatectomies, showing that, by using her protocol, men had less leakage (in amount and duration) with 1 in 6 men having no incontinence at all!

Each week as I prepare to teach the Yoga for People with Cancer class, I seek some inspirational words.  I'd decided that we'd visit and revisit Tree pose in all its iterations, from lying to long sitting to static tree to moving tree to a pre-savasana resting tree, each time finding a new kind of balance.  This poem, written by Ilan Shamir, really struck a chord with me and so here's playful blog to share with you.  As we transition into spring, let's celebrate the catkins on the hazelnuts, the swelling buds on the maples and our own roots and growth!

Advice from a Tree

Dear Friend
Stand Tall and Proud
Sink your roots deeply into the Earth
Reflect the light of your true nature
Think long term
Go out on a limb
Remember your place among all living beings
Embrace with joy the changing seasons
For each yields its own abundance
The Energy and Birth of Spring
The Growth and Contentment of Summer
The Wisdom to let go like leaves in the Fall
The Rest and Quiet renewal of Winter.

Feel the wind and the sun
And delight in their presence
Look up at the moon that shines down upon you
And the mystery of the stars at night
Seek nourishment from the good things in life
Simple pleasures
Earth, fresh air, light
Be content with your natural beauty
Drink plenty of water
Let your limbs sway and dance in the breezes
Be flexible
Remember your roots
Enjoy the view!

Menopause.  Hot Flashes.  Uncomfortable, disturbing, nauseating, fuzzy brain, disturbed sleep....hot flashes are listed as one of the most negative aspects of our peri to post menopausal years.  We begin to feel like Goldilocks, desperately seeking a "not too hot, not too cold, just right" kind of world.

75% of women have hot flashes during their menopausal transition.  Moderate to severe hot flashes typically last 7 to 10 years on average and less frequent or severe (either end of the spectrum) can last even longer.  Let's talk about how you can influence the frequency and intensity of hot flashes, sleep and feel better!

We enjoy a breadth of temperatures in our lives before surgical (full hysterectomy), chemical (induced by medication) or natural menopause....we can be too warm or too cold and simply put on or remove a layer of clothing and stay comfortable.  This is due to our clever hypothalamus, the part of our brain noticing and controlling thermoregulation.  When it sense that we're becoming too warm or cold, it send signals to our organs, muscles and hormonal systems.  They collectively respond to bring our internal core temperature back to normal.  With menopause, the range of acceptable fore body temperature is drastically narrowed.  We become more sensitive to external temperatures so much that we experience a sense of panicking with crisis messages zipping around, causing blood vessel dilation, sweating, wakefulness, peeling off of clothing/blankets....the list is long!

Why now?  There are a number of theories including declining estrogen theory, elevated noradrenergic activation (stress) theory, east vs. west (consumption of phytoestrogens) theory, stress-coping theory, perception of menopause theory and thyroid dysfunction masquerading as menopause symptom theory.  Estrogen does 400 jobs in our premenopausal body each and every day.  We have declining estrogen with menopause, reducing support to our hypothalamus, making our threshold to heating much more sensitive.  Simply adding estrogen sounds logical, but isn't an answer for women who are sensitive to estrogen (a history of estrogen related cancers), nor for those who are estrogen dominant (actually have low progesterone in relation to their estrogen).  This is a condition that is more common in recent decades due to chronically high stress hormones that creates chronically low progesterone in relation to our declining estrogen.  It's all in the balance.

We need stress hormones in our lives in order to wake up each morning, but again, not too much stress. With our reducing estrogen, we handle stress less well after menopause due to altering of our neurotransmitter activity.  Rather than thinking that we've become wimpy, we now know that our stress response is more sensitive through menopause due to physiological changes!  Those of us who dread menopause or fear aging, those who are stressed by daily life (financially, physically, relationally, emotionally), those who have suffered trauma and those who smoke and/or are obese are likely to experience more frequent, intense and long lasting hot flashes.

Triggers for hot flashes include caffeine, dehydration, alcohol, smoking, sugar, hot foods (spicy and temperature), stressful situations, stressful thoughts, sleeping in a hot/unventilated room, wearing too many clothes/blankets, focusing on/worrying about hot flashes/aging and not prioritizing restoration time (like quietude, meditation, prayer or nature walks).  Hmmmm......notice any patterns for you?

Begin by keeping a hot flash diary for a week.  When do they come?  How severe are they?  How long do they last?  Which of the triggers can you align with your hot flashes?  Each woman is unique and it's up to you to sort yourself out.  Be your own personal sleuth.

Some general guidelines are:  Address one personal trigger per week from your list, beginning with your toughest personal challenge.  Stop and congratulate yourself, knowing that the balance of the list will be easier.  Learn and practice calm breathing by doing the following:  breathe in for a count of four and out for a count of four.  Keep going for 5 minutes, building up to 10 minutes, repeating 2 - 4x/day.  Lose 5 pounds; repeat if needed.  Begin a gratitude journal, noting 3 items each day that you're grateful for.  Controlling your controllables is your first step!  You'll sleep better, fell better and enjoy life more.

 
Constipation. If your back passage (bowel release and anorectal action) isn't working well, nothing else in your pelvis (bladder, intimacy, pelvic organ support and core strength) will be working well.  So, brace yourself, let's talk constipation!
 
Do you enjoy a consistent, full, complete and satisfying bowel movement every morning?  BMs should be a minimum of every 2 - 3 days and a maximum of twice daily.  You should never need to rush, have skidmarks in your undies or lose stool without you knowing or before you're ready.  Ever.  The stool should be firm but not dry or very cracked, smooth but not sticky and medium sized to pass with comfort.  It should be brownish, of a consistent smell and without mucous or blood.  It shouldn't be painful to release your stool nor should you bear down.  Hemorrhoids can come with pregnancy or stress, but shouldn't be persistent.  You should be able to travel or change your routine without upsetting your BMs.  Your bowels are meant to digest your food and drink, transfer nutrition to your body, then get rid of the waste.  It's a beautiful system!
 
How does it actually work?  When you take that first warm drink in the morning, the sphincter between the esophagus (food tube) and the stomach sends a signal to the rectum that today's food is en route.  Yesterday's waste is nudged along the colon, down the digestive tract and into the rectum.  The sphincter at the end of the rectum opens up.  Counterintuitive?  Stool has just landed and it opens up to take a sample.  It checks if it's gas, liquid or solid. If it's gas, it nudges you. If it's liquid, it slams shut and gives you to signal that you need to move!  If it's solid, it shuts firmly and gives you the message, "Time to go to the toilet".  Don't delay.  It nudges, you calmly go.
 
Toileting habits are important. Sit comfortably and relax.  Your knees should be slightly higher than your hips, supported on a stool or block. Breathe into your belly and sense your pelvic floor softening, descending, and the sphincters opening up to let stool pass.  If you have the urge to push, don't!  Just breathe into your belly and do a bass hum, low growl or pursed lip outbreath to protect your pelvic floor.  Keep allowing your system to release and let go.  Don't stop the stool until your body says you're done.  Then belly breathe again, rock your pelvis and enjoy a few moments of quiet.  When you're sure you're done, do a few gentle pelvic floor squeezes to help clear the anus so that wiping is gentler and more complete.
 
You can support your digestive system.  Keep hydrated, drink mostly water, and enjoy a drink of warm water with tooth-brushing to help your stool stay hydrated overnight.  Be cautious with fibre, adding a little at a time.  Pay attention to the foods that your body finds a problem - what makes your stool too solid and/or what makes it too loose?   What gives you gas?  You're unique, so learn about you.  Support your system with a heated wheat bag and a massage.  Help your system release its waste products after all the work it's done for you.  Depending on your issues, there are specific techniques, stretches, breathing patterns and habit changes that will help you enjoy lovely BMs that support your health.
 
If you have specific problems with your bowel release, a pelvic physiotherapist provide you with with an internal and external assessment and treatment plan just for you.  Your digestion, bladder, pelvic organ support and intimate life will thank you!

 
Pelvic pain is complex and has many faces.  We've talked about Painful Periods, Endometriosis and now we're going to tackle Bladder Pain Syndrome.
 
Bladder Pain Syndrome may have begun like this:  You had a urinary tract infection that just didn't go away.  You felt urgency to void.  You felt pain just above your pubic bones (where your bladder lives), in your perineum and/or in the urethra (the tube from the bladder to the outer world). When urinary tract infections became chronic, the old thinking was that the interstitium (bladder lining) was inflamed, ergo the outdated name "Interstitial Cystitis". Bladder Pain Syndrome is far more complex, the name far more descriptive. 
 
In 2018, we know the onset of BPS is more like this:  Your bladder thinks that it's under threat…..a grizzly is at its door.  Your bladder may have suffered at some point in your life, perhaps when you were a child (Chronic infections? Withholding voiding? Difficulty with bedwetting?).  The part of your brain that worked with your bladder remembered this sense of distress.  Later on in life (with puberty, onset of intimate relations, stressful situations, baby having, an accident or menopause), your bladder had "flashbacks" and kicked into that difficult memory.  Your immune system pitched in, bringing on an immune response and inflammation.  Your bladder nerve endings and the nerve pathways to the brain were woken up.  Your tendons, muscles and fascia tightened up in order to protect the area. 
 
The outcome?  You may develop a hypersensitive, overactive, inflamed bladder.  As your bladder fills, it naturally stretches.  That tight and inflamed bladder isn't so keen on stretching, sending a threat message to the brain.  Your bladder naturally fills to 500-ish mls., but with BPS it can become painful at only 100 mls..  The bladder may also not welcome urine due to the inflamed lining, so you may feel a sense of urge to get rid of it…now!  If you experience these feelings for more than three months, your brain begins to focus on the bladder, becoming attentive to all bladder sensations from a little urine to moderately full to urgency to pain!  The natural voiding reflex and habits become distorted over time and your bladder forgets how to feel the "Oh, I'm getting full…..I'll have to go to the loo soonish, but no rush" sensation.  The rising tension in the pelvic floor creates more problems.  Toilet time naturally involves releasing the pelvic floor along with opening of your sphincters in a lovely dance.  With a tight pelvic floor, your urine stream may become slow, interrupted, painful and incomplete.  Intimacy may become painful.  You may have an accompanying challenge with bowel release (not constipation….it's the letting it go part that becomes slow and/or painful).  Your stress system and brain become alerted over time and this increases your perception of pain; it attaches it to your emotional state.  If you haven't slept, are having a bad day or have stress, you'll feel BPS more than you would have otherwise.  It's just all so connected.
 
What can you do about it?
 
Find a pelvic certified physio.  You'll be asked about how your bladder functions, how often you void, how it feels before, during and after voiding, how your bowel works (loading, comfort, movement, frequency), pelvic floor function, deep core function and how your life is working (your nutrition, sleep, understanding of pain, pelvic systems and stress management).  Your internal and external pelvis and deep core will be assessed.  Research has shown us that your pelvic floor needs to be calmed down in its hypertonicity (tension), pain and function or the dysfunction and pain in your bladder won't change. You will be taught pelvic floor releases with breathing patterns, general and specific stretches and perhaps the use of a wand (a pelvic trigger point tool for you to use). An elimination diet is helpful, but no two women with BPS have the same dietary triggers.  Eat food that agrees with you.  Get good sleep and downtime.  Find and manage your stressors.  Bladder Pain Syndrome can be managed well.  You can experience a cascade of wonderful changes when you take charge of your own health.