After Ellen* had a hysterectomy in her mid-20s, her doctor started her on oestrogen. About 30 years later, when she was in her 50s (and past the point when menopause would normally occur), she was advised to stop taking the medication. Soon after, "everything fell out," she says. “One day there was a bulge coming out of my vagina... it felt like it was a golf ball.”
While needing a hysterectomy at such a young age is unusual, the experience of feeling like your insides are not where they belong is, unfortunately, rather common. It's called pelvic organ prolapse (POP), and two out of three women will experience it in their lifetime, according to obstetrician Susan Hendrix.
Pelvic organ prolapse means that one of the organs near the vagina and uterus “herniate into the vaginal space,” according to the American College of Obstetricians and Gynecologists. There are three kinds: cystocele, when the bladder bulges into the vagina; rectocele, when the rectum bulges into the vagina; or enterocele, when the small intestines push the uterus into the vagina.
Hendrix says prolapse is so common because in order for women to have children, they have a large hole in their pelvic floor. “Any time you have an opening and your entire abdominal content sits on that opening, pushing down, gravity alone will do its work,” she explains. “On top of that, pregnancy creates a lot of damage to the tissues, and allows things to fall.”
Certified nurse-midwife Chloë Lubell says part of the reason prolapse is such a frequent problem is because pregnancy care is primarily focused on the baby. “The birth parent's mental and physical health is often ignored during the process unless it's directly related to improving the baby's outcomes,” Lubell says. “After the baby is born, the birth parent only has one or two (if they're lucky) more appointments with their ob-gyn provider.”
Lubell adds that in other countries, such as France, “pelvic floor health is incorporated into the postpartum care regimen, significantly decreasing the number of people suffering from incontinence or prolapse.” Other countries also tend to offer longer maternity leaves, which allows mothers more time to heal and support their bodies after the stress of giving birth.
A variety of treatments are available, but step one is to see your doctor—and many women are too embarrassed to do so. “Often times they let this go and they won’t tell anybody until it gets so terrible that they are forced to go and do something,” Hendrix says. You shouldn't have to feel that way: The sooner you speak up, the sooner you'll get help.
Once you do talk to your gynaecologist (or, even better, a urogynaecologist), you can discuss possible remedies, which range from conservative exercises to major surgery. “If a patient is very aware that something is protruding, and she feels like she's sitting on an egg or has irritation from those areas rubbing in her underwear, obviously she's going to be more inclined to have some kind of [surgical] repair,” Hendrix says.
Your options may include:
- Pelvic floor therapy. This involves strengthening the three major muscles of the pelvic floor, which wrap around the bladder, rectum, and the vagina. An expert will instruct you on how to contract and relax those muscles, usually while using biofeedback provided by a probe that goes into the vagina and/or rectum. “If the prolapse is mild, this might improve your muscle strength enough to prevent the need for surgery," says Hendrix.
- Hormones. If you're postmenopausal and vaginal atrophy is the main issue, using oestrogen (local, like via a cream or insert, or systemic, perhaps by taking a pill), might help.
- Pessary. A plastic device shaped like a ring or doughnut, a pessary helps prop up your organs, such as a uterus that's in the wrong position. You place it into your vagina yourself and remove it for cleaning.
- Transvaginal mesh. Many women have had a procedure in which a piece of mesh is implanted and used to support a weakened vaginal wall. The (major) catch is that many women have had complications, and this procedure was re-classified as high risk. Currently there are tens of thousands of women suing the manufacturers of the products, so this is unlikely to be your best bet.
- Hysteropexy. This surgical procedure that involves lifting up the uterus and attaching it back in place is rarely done, says Hendrix, and ACOG warns that there's limited evidence about its safety and efficacy. That said, a study in BMC Women’s Health found that hysteropexy is just as effective and safer than a hysterectomy for prolapse.
- Hysterectomy. "For some women hysterectomy is a big relief,” says Cindy Pearson, executive director of a consumer health advocacy group. But Pearson says hysterectomy is badly overused. “Unless women have really disabling symptoms, their surgeon should be encouraging them to try something less invasive first.” Lubell also warns that this drastic procedure in which the uterus is removed might not even solve your prolapse problem. "Hysterectomy does not in fact help with pelvic organ prolapse, since other organs will just fall into that space,” she says.
More research about prolapse is needed, but fortunately the field of urogynaecology (a sub-specialty of obstetrics and gynaecology) is expanding rapidly. “There are new fellowships and a certification process has just been instituted in the last couple of years,” Hendrix says. That means there are more people that are highly trained doing research about the causes of these problems and what will be most effective in repairing them. “It’s an exciting time for women because we’re getting a lot more information about these conditions,” she says.
*Name has been changed