Genitourinary syndrome of menopause (GSM) is a collection of symptoms and signs associated with declining estrogen and other sex hormones during the menopause transition. When we think of menopause, usually the experience of weight gain and difficulty losing weight, mood swings, brain fog, and the ever-dreaded hot flash comes to mind, but not necessarily some of the more specific changes to the genital and urinary tracts. Most of these symptoms are progressive and do not resolve without treatment or behavioral changes. According to the North American Menopause Society (NAMS), 50% of postmenopausal women maybe affected by GSM and many women may not report the symptoms because they are embarrassed, are unaware that their symptoms are related to menopause, or believe that their symptoms are just an inevitable part of aging.

Symptoms of GSM
Vaginal symptoms include genital dryness, burning, irritation, decreased lubrication with intercourse, pain with intercourse, and impaired sexual function. The tissue of the vulva and vagina become more thin and delicate and the vagina can become less elastic resulting in a shortened vaginal canal. The opening of the canal can also shrink in diameter with less stretch to the tissue. Urinary symptoms can include recurrent urinary tract infections due to the rise in the vaginal pH which suppresses the level of the "good" bacteria, urinary incontinence, increased urinary urgency/frequency, increased amounts of urine left in the bladder when voiding, and a reduced urine flow. Some of the physical changes to the urinary tract include the thinning of the lining of the urethra and bladder, shortening of the urethra, a weakened urethral sphincter, and a reduced bladder storage capacity.

Treatment Options
Some simple changes made in skin health and hygiene can help with some of the irritation and dryness experienced. Practical suggestions include avoiding perfumed soaps and feminine hygiene products, using mild unscented laundry detergents and plain white unscented toilet paper, and wearing breathable cotton underwear. There are several helpful products such as Lubrigyn lotion and Luvena Therapeutic Wash which both can be found over the counter (OTC) in your local drug store such as CVS or Walgreen's. OTC vaginal moisturizers are also available in the Lubrigyn and Luvena line of products. Other options to use are Vitamin E oil and coconut oil. Consistent use of a vaginal moisturizer several times a week can help to restore the ridges and elasticity of the tissue. The use of a lubricant during intercourse is also highly recommended. Look for products that do not contain parabens or glycerin or try some of the more natural products such as coconut oil, apricot seed oil, or emu oil. For some women, OTC products or hygiene changes may not provide enough symptom relief. Discussions with your physician on the use of topical vaginal estrogen if appropriate can be an option to also address GSM symptoms. Vaginal estrogen can come in various forms. The Estring is an estradiol filled ring, which can remain in the canal for three months and delivers a slow steady dose. Other vaginal creams and tablets are available too. These products placed in the vagina stay locally and do not have the systemic effects that taking a patch or an oral pill would have.

Pelvic floor physical therapy can also be of benefit in combating some of the symptoms of GSM. The changes to the urogenital system with hormone fluctuations can trigger muscle spasms along with the loss of elasticity in the canal which can lead to pain. Additionally, this may cause changes in bladder and toileting habits which can exacerbate urinary symptoms. A PT can assess and develop a program specifically for you to address many of the GSM symptoms and get you moving through this transition. If you are experiencing any of the symptoms of GSM, do not hesitate to call. We can help! Come and see a physical therapist at CTS for an individualized program!!

Jill Menefee, PT

When the foot hits the ground, your lower body performs a complex series of joint and muscular reactions to help keep you upright, move you forward, and absorb shock (originating from a 2-3x increase in body weight moving through your foot while walking). With summer bringing warmer weather, our clothing - including our footwear - will change. This change in footwear correlates to a change in how we walk. One common summertime feature is flip-flops. Flip-flops can have a negative effect on walking, and thus be a contributor to lower body injuries. Rather than asking you to stop wearing flip-flops (which I personally have not done yet), let's educate ourselves so we can make an informed decision on what to wear, how long to wear them, and possible alternative solutions.

Walking can be broken down into two phases: Stance and swing. Stance is when one or both feet are on the ground, and swing is when the foot in in the air. Stance makes up about 60% of this cycle, and can be broken down into five stages.

1. Heel Strike:
This is when your heel first touches the ground.

2. Early Flat Foot:
This is when the body is moving forward and the ankle moves into a neutral position. The end of this phase is when the body's center of gravity passes over the top of the foot. The goal of this phase is for the foot to be a shock absorber as the weight moves forward.

3. Late Flat Foot:
This phase is when the center of gravity is moving forward toward the toes and ends when the heel starts to rise off the ground. In this phase, the foot transitions from being a more flexible shock absorber to one which is more rigid, giving the body leverage to move forward.

4. Heel Rise:
This phase is when the heel is rising while the foot continues to be a rigid lever to allow the body to propel forward. During this phase, the foot can experience double to triple the force of a person's body weight moving through it.

5. Toe Off:
This phase is when the toes leave the ground. Ideally, you are pushing through your toes, including your big toe. This phase can be considered the beginning of swing phase.

Now that you can know the basics of walking, walk and see how you move through your foot. Do you land on your heel, roll through your entire foot, feel your heel rise? Are you beginning your swing before you roll through your big toe? The next question is what you are wearing on your feet - if you are wearing anything at all! Compare how you walk in different footwear. Now, back to flip-flops - why should you be more aware when wearing them? The answer is that the loading pattern through your foot will be different, and can affect the biomechanics to your knees, hips, and back. For instance, in order to hold flip-flops on your foot, you must tighten up the underside of your foot and curl the toes. Even if you are heel striking and rolling through your foot, you will not be loading optimally because you are loading on an altered foot that's gripping your shoe. The best shoe for you is one that is supported on your foot. This is so all of the muscles involved are doing the job they're designed to do rather than trying to hold footwear in place.

So should you get rid of flip-flops? I cannot answer that for you. However, recognizing the changes they make to your mechanics, you should think twice before wearing them for long periods of walking AND promise yourself that you will stretch your feet and legs to help offset the extra work.

Elizabeth Leeds, PT, DPT, FAFS