Although pelvic floor yoga has been advised after childbirth and pelvic surgery for decades, it has never had a firm evidence base.
In California, a randomised trial was conducted with 240 women aged between 45 and 90. All reported urge, stress or mixed incontinence.
One group were given 12 weeks of twice weekly group instruction of pelvic floor Hatha yoga and the other group was given the same time and frequency of general muscle stretching and strengthening exercises. The women all had to keep three day diaries of their voiding habits.
At the start the mean frequency of unwanted voiding occurred 3.4 times a day. This fell to 1.1 episodes with pelvic yoga and 1.5 with general physical conditioning.
There were similar improvements whether the woman had stress or urge incontinence.
My comment: I’ve been doing a wide variety of exercise almost daily for the last 35 years, including pelvic floor exercises. Although pelvic floor exercises are taught to almost every pregnant woman, as a GP, nearly all women I met who had incontinence said they had rarely practised the exercises or had given them up after a few months. Due to my exposure to incontinent women I have been really good at keeping my pelvic floor strong. Whatever your age, but particularly if you have been pregnant or have hit the menopausal years, it seems a good idea to make pelvic floor exercises a daily habit.
The current maternal death rate in the UK is the highest it has been in the last 20 years. These deaths include all deaths in women who are pregnant or within 6 weeks of delivery. The most frequent causes are blood clots 16%, Covid-19 14%, and cardiac disease 13%. 275 deaths occurred.
Deaths between 6 weeks post partum and one year also occurred in 329 women. Most of these were due to mental health problems 34%. Substance misuse and suicide were the leading causes.
Black women had three times the death rate of white women. Asian women had double the risk.
Women over the age of 35 had triple the risk of those aged 20-24.
Women in the most deprived areas had triple the risk compared to women in the least deprived areas.
9% of women who died had multiple disadvantages such as mental ill health, substance abuse or domestic abuse.
Overall, the death rate rose from 11.66 per 100,000 pregnancies in 2017-19 (pre-covid) and 13.56 per 100,000 in 2020-22 (during Covid). Some of the deaths were related to delays in pre-hospital care which were directly related to the pandemic. Others were due to the fact that women are getting pregnant later in life and obesity continues to rise.
One in four women who died of venous thrombo-embolism died in the first trimester of pregnancy, sometimes before any risk evaluation by hospital teams could be done. The Royal College of Obstetricians and Gynaecologists want the VTE risk assessment tool to be restructured so it is clear and easy to use. They want GPs to obtain timely specialist advice, with clear pathways of referral.
My comment: In most of my work as a GP, the first port of call for a woman who thought she was pregnant or who had confirmed a pregnancy was the GP. In the last ten years of my work, since around 2010, however, the entire pregnancy referral process was put in the hands of midwives. Once in the hands of the midwife, I would imagine that it would be easy for screening tools to be employed, and appropriate consultant referrals made. It would seem to me that in order to identify women who are at risk of VTEs in pregnancy, a screening tool that could be done online by women themselves or by other health care professionals will be needed. This could be done when a woman presents for contraception advice or opportunistically when she seeks routine health care. This could identify to individual women whether they need to be fast tracked to an obstetrician in the event of a pregnancy occurring, instead of waiting on the usual midwife led pathway.
Adapted from Top Tips for Primary Care. Dr Victoria Barber scrutinises the role of primary care in the identification of Ovarian Cancer, an often overlooked malignancy. August 21 2023.
Ovarian cancer is often considered difficult to diagnose, particularly in the early stages, so women need to be aware of when they should visit their General Practitioner and what symptoms may occur.
The symptoms of ovarian cancer can occur with many other conditions too, and this can lead them to being overlooked by both patient and doctor. Yet, there are a group of symptoms that need attention. Ovarian cancer occurs more often in women older than the age of 50, but does occur in young women too.
The symptoms to look out for are: pelvic or abdominal pain, persistent abdominal distention also referred to as bloating, feeling full after very small meals or loss of appetite, and urinary urgency or frequency that is unusual for that woman. Frequent is considered to be more than 12 times in a month or 2 to 3 times a week. Persistent means beyond the time that you would expect a simple cause of a symptom to resolve.
Other symptoms of cancer in general are unexplained changes in bowel habit, unexplained weight loss, and unexplained fatigue. Ovarian, other bowel or pancreatic cancers, leukaemia, lung, and urological cancers can cause these. Further history and examination will help clarify the likely source of the problem and useful investigative tests and referrals.
If these symptoms are reported to the GP, the GP is best to examine the patient and also to take a blood test called the CA125. Next steps will depend on that blood level. Levels over 35 will usually indicate referral for an urgent ultra sound scan of the pelvis. If the scan is abnormal, an urgent “cancer suspected” appointment to gynaecology should be obtained. This is usually within two weeks in the NHS.
If the symptoms are not thought to be of a potentially serious nature or if a CA125 is not done, it can be helpful to arrange a review appointment for when the GP would expect resolution of the symptoms experienced. This is so that persistent symptoms are not missed.
Breast and ovarian cancer tend to run in families and genetic testing may be indicated in some patients.
Sometimes the urinary symptoms sound like a urinary infection but the dipstix test or bacteriological test will be negative. This can be a situation that calls for a CA125 tests for clarification.
Irritable bowel syndrome should not be considered as a new diagnosis in people over the age of 50. It is more likely to be something more serious such as bowel cancer, ovarian cancer, coeliac disease or colitis.
In young women, under the age of 50, bloating of the abdomen related to irritable bowel syndrome tends to come and go throughout the day, be related to meals or stress, and usually improves with having a bowel movement. In ovarian cancer, the bloating tends to last all day, can be there on waking, and is usually unaffected by passing a bowel movement.
Everyone knows how hard it is to shift body fat after having a baby. A recent study suggests that adopting a low carb diet featuring plentiful meat/poultry/fish and animal fats was more successful than having a low carb diet based mainly around plant foods.
Readers who are keen to shed their post holiday season weight gain may also find this information useful.
Low-carbohydrate diets (LCD) have been considered a popular dietary strategy for weight loss. However, the association of the low-carbohydrate dietary pattern with postpartum weight retention (PPWR) in women remains unknown.
The present study involved 426 women from a prospective mother-infant cohort study.
Overall, animal or plant LCD scores, which represent adherence to different low-carbohydrate dietary patterns, were calculated using diet intake information assessed by three consecutive 24 h dietary surveys.
PPWR was assessed by the difference of weight at 1 year postpartum minus the pre-pregnancy weight. After adjusting for potential confounding variables, women in higher quartiles of total and animal-based LCD scores had a significantly lower body weight and weight retention at 1 year postpartum (P < 0.05). The multivariable-adjusted ORs of substantial PPWR (≥5 kg), comparing the highest with the lowest quartile, were 0.47 (95% confidence interval 0.23–0.96) for the total LCD score (P = 0.021 for trend) and 0.38 (95% confidence interval 0.19–0.77) for the animal-based LCD score (P = 0.019 for trend), while this association was significantly attenuated by rice, glycemic load, fish, poultry, animal fat and animal protein (P for trend <0.05).
A high score for plant-based LCD was not significantly associated with the risk of PPWR (P > 0.05). The findings suggested that a low-carbohydrate dietary pattern, particularly with high protein and fat intake from animal-source foods, is associated with a decreased risk of weight retention at 1 year postpartum. This association was mainly due to low intake of glycemic load and high intake of fish and poultry.
The Times recently published a long list of exercise sites that you can get for free or pay for. Being a home exercise enthusiast I read this carefully and decided to try out the sites they listed as being FREE. These were my favourite ones. All had a variety of exercises eg low and high impact aerobics, walking, weights, rubber bands, stretching, relaxation and even dressing, hair and make up tips.
Top of the pops was Fabulous 50s. There are over a hundred workouts on this site. All are one to one, and set in beautiful Australia. This lady’s house is so clean, tidy, uncluttered that I was immediately pea green with envy. Of course, if I moved into her house, it wouldn’t stay that way for long. There is a fantastic range of exercises and from the ones I have tried, they were well produced and constructed, and even if you are a complete beginner, are pretty easily done. They range in time from 5 minutes to 30 minutes really giving you plenty of options no matter how hard pressed you are for time.
Mad fit, Lucy Wyndam-Read and Fitness Blender also are free and have multiple workouts in terms of types and durations. They seemed more tuned to the younger or fitter age group than Fabulous 50s and I have only done a few of them being 61 with some unfortunate back issues right now. They are not quite as beautifully produced as Fab 50s but they are free!
You will get adverts popping up during all these workouts. Now this is where you have to be careful because the marketing folks know who they are aiming at here and the top products seem to be wrinkle cream, make up and chocolate. It doesn’t matter how lucious it looks. Do not buy it. Because you will eat it.
Adriene is purely a yoga site. This is free too, and she sometimes has her dog with her. Again, there are a lot of different length and types of workout.
Now, if you have a smart phone, a tablet, a pc or a smart television, whatever your favourite form of home exercise is, and even if you only have five or ten minutes, you can workout for free at home.
Adapted from Antvorskov JC et al. Association between maternal gluten intake and type one diabetes in offspring. BMJ 22 September 2018
This research was based on a study of Danish women’s food frequency questionnaires completed 25 weeks after their first pregnancies ended. The incidence of diabetes in the children was then noted from January 1996 till May 2016 from the Danish Registry of Childhood and Adolescent Diabetes. After certain exclusions had been made over 63,500 were analysed.
The mean gluten intake per day was 13g ranging from 7g to more than 20g per day.
The incidence of diabetes in the child increased proportionately according to gluten intake. The women who had 20g or more intake had double the type one diabetes in their offspring compared to those who ate 7g or less.
As type one diabetes has risen seemingly inexplicably over the last few decades, there has been a lot of consideration into possible environmental triggers. Gluten is a storage protein found in wheat, rye and barley. In animal studies, a wheat free diet in the mother has been found to dramatically reduce the incidence of diabetes in the child.
It has been suggested that gluten can affect gut permeability, gut microbiotica and cause low grade inflammation.
Although there is this association between gluten and type one diabetes it could be that other factors, for example the advanced glycation products from the baking process, that are to blame. Unwanted additives to grain could also be a factor eg mycotoxins, heavy metals, pesticides and fertilisers.
Mothers who eat a lot of gluten may similarly feed their children a lot of gluten. They also may pass gliadin from wheat into the breast milk.
Although this research suggests that high amounts of gluten may be problematic in pregnancy, further research will need to be done before dietary recommendations are likely to be changed.
A retrospective analysis from Quebec of 2 million pregnant women who had delivered between 1989 and 2016 showed that offspring of women who had become pregnant after bariatric surgery had roughly twice the risk of birth defects compared to women who were not obese or who were obese but had not had surgery.
The defects were mainly heart and musculoskeletal defects.
My comment: This short report does not go into possible causes for this. You would have thought that the risk would have been reduced to the level of the non obese women. I wonder if nutritional issues have a part to play as after bariatric surgery long term vitamin supplements need to be taken.
Adapted from Editorial BMJ 19 October 19 by Janice Rymer et al.
In the UK most women go through the menopause aged between 45 and 55. About half of them will get symptoms such as flushes, sweats, low mood, anxiety, joint and muscle pain, vaginal dryness, reduced sex drive, and hip fractures in later life. Hormone replacement therapy can turn these symptoms around.
Women’s health specialists are concerned that a meta-analysis published in the Lancet does not evenly show the benefits of HRT compared to the risks and think that the NICE guidance in 2015 looked more comprehensively at all the available evidence. They don’t want either women or doctors to stop HRT unnecessarily.
The Lancet showed that in the UK one in 16 women who have never taken HRT will develop breast cancer between the ages of 50 and 69. If a woman of normal body mass index (under 25) starts HRT in her 40s or 50s the additional risk of getting breast cancer is one in 200 for oestrogen only HRT, one in 70 for daily oestrogen and progestogen for part of the month, and one in 50 for preparations with a mix of oestrogen and progesterone daily. But body weight and alcohol have a greater effect on getting breast cancer than HRT. For instance, being overweight or obese will increase the rate of breast cancer six times compared to combined HRT.
The Lancet study looked at how many cases of breast cancer started but did not look at the mortality rate. A recent systematic review did. This showed that if a woman started HRT close to the menopause there was an apparent reduction in all cause mortality and cardiac death with no evidence of an increase in deaths from breast cancer.
The womens’ health specialists are concerned that the bone benefits and cardiac benefits, especially for women going through an early menopause, will be ignored if undue weight is put on the small increase in breast cancer diagnosis, over the symptomatic benefits and improvement in total mortality.
From Ojo O et al. The effect of vitamin D supplementation in women with gestational diabetes mellitus. A systemic review and meta-analysis of randomised controlled trials. Int J Environ Res Public Health. 2019:16(10)
A meta-analysis has indicated that various factors relevant to improved blood sugar control are likely to be improved by vitamin D supplementation in a total of 173 women with gestational diabetes.
Fasting blood glucose decreased by a mean of 0.46 mmol/L
Glycated haemoglobin decreased by a mean of 0.37%
Serum insulin reduced by a mean of 4.10 uIU/mL.
My comment: Although the improvements are small, vitamin D supplements are inexpensive, easy to take and do not have the side effects of other medications.
Being a working mother doesn’t just feel stressful, it alters your physiology.
Researchers at the universities of Manchester and Essex studied 6025 people. They collected information about their working and home lives. Hormonal levels and blood pressure were checked too.
When 11 biomarkers of stress were tested, these were 40% higher in women who worked full time and were raising two children at the same time. One child raised the levels by 18%. Part time workers, job sharers and those with flexible working arrangements were fewer hours were worked had less stress. Flexible working or remote working with no reduction in hours did not lower stress levels.
The authors said, ” Work-family conflict is associated with increased psychological strain, with higher levels of stress and lower levels of well being. Parents of young children are at particular risk of family-work conflict.
Diabetes Diet 