When she was told she could no longer exercise, go running or even pick up her toddler, Pilates instructor Holly Puddephatt thought life as she’d known it was over.
The fit and active 37-year-old from Leeds was diagnosed with a prolapsed bladder and womb 18 months after giving birth to her daughter Thea, now three – and informed she had to ‘live with it’.
‘I was dismissed by my GP and told to just go home,’ she says. ‘I couldn’t believe I was being treated so badly.’
A prolapsed womb (known medically as uterine prolapse) is where the muscles and tissues supporting the womb become weak, causing it to slip down into the vagina.
‘In severe cases, the uterus may even protrude outside the vagina,’ says Dr Shazia Malik, a consultant obstetrician and gynaecologist and UK medical director at virtual women’s health clinic Daye.
The condition is one of a group of pelvic floor disorders collectively known as pelvic organ prolapse – where the supporting tissues have weakened so that organs in the pelvis, including bladder and rectum, drop from their normal positions into the vagina.
Pelvic organ prolapse affects one in ten women over 50, says the Royal College of Obstetricians and Gynaecologists.
It can be caused by a number of factors: ageing (as the muscles lose their elasticity); diseases that weaken the connective tissues (including genetic disorders); pelvic floor injuries; and having had a hysterectomy.
Pilates instructor Holly Puddephatt thought life as she’d known it was over when she was diagnosed with a prolapse
But less well known is the significant role played by childbirth – specifically a natural vaginal birth – in otherwise fit and healthy women such as Holly.
A US study, published in the International Urogynecology Journal in 2013, suggested that a vaginal birth significantly increases a woman’s odds of a prolapse. As many as 50 per cent of women may have some degree of prolapse afterwards, says Jo Dafforn, a women’s intimate health physiotherapist and pelvic health clinic lead at Nuffield Health.
Many of those affected may not even realise and ‘could be walking around symptom-free’, she adds.
But one in 12 women with pelvic organ prolapse will report symptoms – such as vaginal ‘heaviness’ or a sensation of dragging, a lump inside their vagina, lower back ache and problems controlling and/or emptying their bladder or bowels – Ms Dafforn says.
And too often women aren’t told help is available, adds Dr Malik. A pre-print study (meaning it hasn’t been peer-reviewed) published last year found that pelvic floor muscle training combined with lifestyle advice significantly improved symptoms and quality of life in women with mild to moderate pelvic organ prolapse.
But women are often too embarrassed to seek help. ‘It’s very important not to feel shame or reluctance to seek specialist assessment and advice,’ adds Dr Malik. ‘It’s common and there are lots of ways to help and no one should have to suffer in silence.’
Holly’s problems began after Thea’s birth – which ended up being lengthy. She had an epidural, which meant she couldn’t feel anything when she was instructed to push by the midwife. Her baby girl was finally delivered by forceps.
Nonetheless, Thea was healthy. Holly was simply relieved it was all over and determined to get on with life as a new mum when they were both discharged from hospital a few days later.
Holly’s problems began after he daughter Thea’s birth – which ended up being lengthy. She had an epidural, which meant she couldn’t feel anything when she was instructed to push by the midwife
She did experience a ‘heaviness down below’ in the following weeks – which she now realises was a symptom of prolapse. But, at the time, she blamed it on having stitches (for an episiotomy during the forceps delivery).
But things didn’t improve. In fact, Holly was even struggling to walk properly. She mentioned the heaviness at her eight-week check – but her doctor merely advised her to do some pelvic floor exercises.
As her stitches healed, Holly started to feel a bit better. ‘I thought I’d come through it,’ she recalls. She and her partner, Curtis, 33, a manager at a gym, threw themselves into being parents and life carried on.
Then, when Thea was 18 months old, Holly began to feel strange once again. ‘It was hard to explain,’ she says, ‘but I felt I had a tampon stuck inside me even though I didn’t’.
She even asked Curtis to check. ‘Nothing was there, but it felt as though something was stuck or hanging out of me.’
Concerned, she saw her GP and tearfully explained the problem. She recalls: ‘I saw a female doctor and thought she’d be sympathetic. But she asked brusquely: ‘Why are you crying?’
The GP did an internal examination, soon after diagnosing a prolapse. Holly was then told nothing could be done – that she’d just have to adjust to it – and there was ‘no point’ in being referred to a specialist. ‘I left in tears,’ she recalls.
The problem worsened: ‘At certain times of my monthly cycle it would be worse and was actually painful. When I walked it felt as if my insides were going to fall out. Sometimes if I just moved, I’d leak urine.’
Holly has benefited from pelvic floor exercises and continues to practise them a year on
Symptoms can come and go like this, says Jenny Pullen, a pelvic floor physiotherapist at Nuffield Health Haywards Heath Hospital. She adds: ‘Many women report feeling it gets worse towards the afternoon and evening – if they’ve been on their feet or carrying their baby a lot that day. It can also feel worse when oestrogen levels are low and at different times of the cycle.’
This is because oestrogen is vital for the strength and flexibility of tissues.
Low levels – during breastfeeding or at certain times of the month, for instance – can lead them to become weaker and also make the vagina feel drier, making the ‘heavy’ sensation of prolapse seem more pronounced.
In addition, changing hormone levels during pregnancy, as well as the weight of the growing baby, can put a strain on the pelvic floor, explains Dr Malik.
Going into labour, and particularly having a vaginal delivery, further stretches these supporting structures. As the baby passes through the birth canal, it stretches surrounding muscles and tissues beyond their normal capacity.
Although the body has an amazing capacity to recover, some women’s pelvic floors never fully regain their original strength, says Dr Malik. Subsequent births generally have a marginal effect, however.
She reiterates that while half of women who have had a vaginal delivery may experience some degree of prolapse, ‘it’s important to note that not all cases are symptomatic or severe’.
And while some women, like Holly, notice symptoms immediately after childbirth, for others there may be a delay ‘of many years’ in between having a baby and noticing the first prolapse symptoms, says Dr Malik, as other factors – including dwindling hormones at the menopause, being overweight, chronic coughing or regularly lifting heavy weights – can have an accumulative effect over time.
Holly finally went to see a private gynaecologist who confirmed that, as well as a uterine prolapse, her bladder had also partly prolapsed into her vagina.
A specialist women’s health physiotherapist gave Holly exercises to strengthen her pelvic floor, which can be very effective in reducing the symptoms of prolapse.
But it’s important to get help from a specialist, adds Dr Malik – not least for checking the exercises are being done correctly.
National Institute for Health and Care Excellence guidelines recommend four months of pelvic floor training for women with pelvic organ prolapse – ‘however, some women will start to see improvement in their symptoms after a few weeks’, says Jo Dafforn.
In severe cases, surgery – to stitch supporting tissues to strong bones or ligaments in the pelvis – may be suggested. Although this can be effective, as with all operations there are some risks.
And there is a chance the prolapse may recur, says Dr Malik. She adds that taking probiotics can help, which maintain a healthy balance of bacteria in the vagina and urinary tract that can reduce the risk of infections (such as urinary tract infections (UTIs), which may exacerbate prolapse symptoms.
Good digestive health helps reduce the risk of constipation, which can also contribute to symptoms.
Holly has benefited from pelvic floor exercises. She continues to practise them a year on. She also uses an internal vaginal pessary (a removable device typically made of silicone) to support pelvic organs, and has been able to return to exercise, weightlifting and picking up Thea.
She’s now opened her own Pilates studio to help other women improve their pelvic floor. ‘I wish I’d been given more support and encouraged to get help sooner,’ she says. ‘I’d like other women to understand that they are not alone and no one should tell them to put up with a prolapse.’
You can find Holly’s story on Instagram @hollyandthea.
