Menstruation, postpartum depression, pregnancy loss, libido issues, menopause; on the vast spectrum of women’s health topics, many subjects once considered taboo have slowly crept into the mainstream. Fem-tech brands (like pelvic floor trainer Elvie or smart breast pump Willow) have helped, filling what was once a white space and spurring conversation by creating products that address an oft-unspoken need and, just as importantly, aren’t cringey to buy. Outspoken celebrities (like Meghan, Duchess of Sussex, Ashley Graham, and Kristen Bell, among others) who are willing to share their own experiences have also helped turn the tide. But one area that has still gone largely ignored, multi-million-dollar Lisa Rinna Depends ads aside, is incontinence—something that Aubrey Hubbell, a serial entrepreneur of female-focused startups, noticed and used as the impetus for Hazel, her new “down-there femme care” brand.
Hubbell became aware of the gap in the market after initiating frank conversations with women who felt not only embarrassed to talk about their incontinence issues but also dismayed by the lack of products and services to deal with it. “These were super stylish successful women and it’s something that was on their minds constantly,” says Hubbell. “We knew we had an opportunity to develop a product where the bar was just so low.” The first product they developed, a disposable, high-waist brief, took into account all of the ideas they got from those initial conversations: No VPL, black, worked, under leggings, and a control top were repeated requests. They were designed with both fashion designers and a material scientist from Johnson & Johnson to be as high-tech as they are stylish. “We made sure women could work out in it, go on long plane or car rides, work a full-time job, and tackle all the things they needed to throughout the day,” says Hubbell of Hazel’s premier product, the High & Dry Brief.
Lauren Stewart, MD, assistant professor in Obstetrics and Gynecology and Urology and director of female pelvic medicine and reconstructive surgery at NYU Langone Health, says there are two types of incontinence: stress incontinence and urge incontinence. The former is leakage of urine during activity like coughing, laughing, sneezing or exercise. “It’s caused by a weakening of the support system to the urethra which is the tube that drains the bladder and can occur for a variety of different reasons, including pregnancy, childbirth or carrying extra weight,” says Stewart. Urgency incontinence is the leakage of urine with the urge to urinate, a symptom of a syndrome called overactive bladder. The medical field, says Stewart, does not have a clear idea what causes it. And numbers may not offer an accurate enough picture of how many women actually deal with either kind of incontinence. “Studies suggest about half of women will suffer from it in their lifetime but numbers may actually be much higher because they are often too embarrassed to bring up their symptoms with a doctor or to endorse their symptoms during a research study,” says Stewart. A recent survey created by the non-profit Center for Intimacy Justice and Origin (a pelvic floor physical therapy start-up) also found that Facebook’s algorithms are blocking and suspending many ads from women’s health companies focused on categories like menopause, pelvic health, sexual wellness, and postpartum issues, making it harder for the conversation—and solutions—to reach more women. (Facebook admits it has made mistakes in enforcing advertising policies that prohibit nudity and has overturned several ad rejections mentioned in the report).
Carrying a pregnancy to term, whether you have a Cesarean section or vaginal delivery, can increase the likelihood of stress incontinence. “We see more severe incontinence and prolapse in women who have larger babies, long pushing phases, instrumental deliveries (like forceps), episiotomies, severe tearing, and giving birth on their backs,” says pelvic floor therapist Dr. Marcy Crouch. A recent study by The North American Menopause Society found that urinary incontinence worsens with age. “The pelvic floor muscles are made of the same type of skeletal muscles as the biceps and quadriceps and, as we age, they lose strength, tone, and size,” says Crouch. Another factor may be hormonal; an effect of lowering levels of estrogen on the vaginal and urinary tissue. “People tend to gain weight as they age, and being overweight or obese definitely contributes to incontinence,” says Stewart. “We also become less active and more sedentary as we age which can result in muscle weakening.” That the pandemic has kept many of us more housebound than usual—and, in turn, often more sedentary—may be having a similar effect. “The more sedentary lifestyle that many of us are leading since the start of the pandemic can contribute to weight gain and loss of muscle strength, both of which can impact bladder function,” adds Stewart. If you’ve had COVID-19, the increased coughing and sneezing that accompanies it can put more load on the pelvic floor and cause an increase in leaking. So too can stress, says Crouch. “We tend to see an uptick in pain and frequency and urgency when our stress levels increase,” Crouch adds.
While brands like Hazel (and Thinx, Here We Flo, and The Honey Pot, too) have started to make excellent products to deal with incontinence, there are medications and treatments to address it as well. For stress incontinence, Stewart says the two most common procedures are urethral bulking injections and the surgical placement of a mid-urethral sling. With the former, a material much like the filler a dermatologist uses is injected into the walls of the urethra to bulk them up. It’s safe, though multiple treatments are often required. In the latter case, a thin mesh strip that provides urethral support is put in in a quick same-day surgery, though you can expect one to two weeks of recovery. For urgency incontinence, there are a number of prescription medications that doctors will often try first. When those fail to help, there is sacral neuromodulation (essentially a pacemaker for the bladder), PTNS (percutaneous tibial nerve stimulation) which are weekly treatments with an acupuncture needle hooked up to gentle electrical stimulation, or even Botox. “A small camera is passed through the urethra into the bladder and a small needle is used to inject the medication,” explains Stewart. “Botox injections calm the bladder through nerve stimulation or what we call neuromodulation.”