You're listening to Burnt Toast! We are Virginia Sole-Smith and Corinne Fay.

Happy Christmas if you celebrate! If you don't, happy Thursday where everything is closed! Either way, today we're taking a look back at your five favorite episodes of the year.

If you enjoy the snippets you hear here, why not give yourself the gift of Burnt Toast? In addition to getting behind paywalled episodes and essays, Burnt Toasties get to join our awesome chat rooms like Team CPAP, Anti-Diet Ozempic Life and Fat Fashion!

🧈🧈🧈🧈🧈🧈🧈🧈🧈🧈🧈🧈🧈🧈

This episode contains affiliate links. Thank you for supporting Burnt Toast when you shop our links!

Episode 225 Transcript

Corinne

So we dropped an episode on Thanksgiving Day, and we're back with another holiday episode. This time we're going to be looking back at your five favorite episodes of the year.

Virginia

This is so fun for me to put together every year. I think this is our second or third time doing it, and it's just really satisfying. Plus the top episodes are not always what I would have predicted! Some are, but some aren't. 

So a little background before we start: Since we moved platforms—we went from Substack to Patreon-—it was actually incredibly difficult to compare all the usual stats. The way Substack tracks episodes and the way Patreon does it—it's not an apples to apples situation. So this isn't the most scientific ranking. But I tried to find the different metrics we're interested in as podcasters —and I found the most popular episode for each of those metrics. 

1. The Episode You Shared Most: Dr. Mara Will Not Sell You A Weighted Vest

Virginia

So this one got the most shares on Substack Notes, on Instagram, etc. This is the one that people sent to other people as much as possible.

Corinne

I was recently recalling this episode because one of my friends texted me to say "What do you think about weighted vests?" And I was like, weighted vests have not gone away. 

Virginia

Did you say I wear a weighted vest all the time? Because that's what I say.

Corinne

My weighted vest is my body. Yeah, I feel like we had a little chat about it. it's one of those things people have got to try for themselves. if you're interested in weighted vest then me being like, "eff a weighted vest" isn't gonna deter you, necessarily.

Virginia

No, no. Well, and they're not harmful. Dr Mara, who is a weight-inclusive doctor and writes the excellent newsletter Your Doctor Friend, was definitely not saying they were harmful. It's just this idea that as a perimenopausal woman, can never be not strength training. it's okay to just go for a walk as well, right?

Corinne

Well, and also, just the thing of, you need to be at least as lean as possible, but put the weight on your body. Just not as part of your body,

Virginia

Yeah, only weight you can remove. That's the deep irony. Let's listen:

Virginia

Okay, so now let’s get into some related weight questions.

I was just told by my OB/GYN that excess abdominal weight can contribute to urinary incontinence in menopause. How true is this, and how much of a factor do you think weight is in this situation? And I think the you know, the unsaid question in this and in so many of these questions, is, so do I have to lose weight to solve this issue?

Mara

Yes. So this is a very common refrain I hear from patients about the relationship between BMI and sort of different processes in the body, right? I think what the listeners’ OB/GYN is getting at is the idea that mass in the abdomen and torso might put pressure on the pelvic floor. And more mass in the torso, more pressure on the pelvic floor.

But urinary incontinence is extremely complicated and it can be caused by lots of different things. So I think what the OB/GYN is alluding to is pelvic floor weakness, which is one common cause. The muscles in the pelvic floor, which is all those muscles that basically hold up your uterus, your bladder, your rectum—all of those muscles can get weak over time. But other things can cause urinary incontinence, too. Neurological changes, hormonal changes in menopause, can contribute.

Part of my size inclusive approach to primary care is I often ask myself: How would I treat a thin person with this condition? Because we always have other treatment options other than weight loss, and thin people have urinary incontinence all the time.

Virginia

A lot of skinny grandmas are buying Depends. No shame!

Mara

Totally, right? And so we have treatments for urinary incontinence. And urinary incontinence often requires a multifactorial treatment approach.

I will often recommend my patients do pelvic floor physical therapy. What that does is strengthen the pelvic floor muscles particularly if the person has been pregnant and had a vaginal delivery, those muscles can really weaken, and people might be having what we call genitourinary symptoms of menopause. Basically, as estrogen declines in the tissue of the vulva, it can make the tissue what we call friable.

Virginia

I don’t want a friable vulva! All of the language is bad.

Mara

I know, isn’t it? I just get so used to it. And then when I talk to non-medical people, I’m like, whoa. Where did we come up with this term? It just means sort of like irritable.

Virginia

Ok, I’m fine having an irritable vulva. I’m frequently irritable.

Mara

And so that can cause a sensation of having to pee all the time. And that we can treat with topical estrogen, which is an estrogen cream that goes inside the vagina and is an amazing, underutilized treatment that is extremely low risk. I just prescribe it with glee and abandon to all of my patients, because it can really help with urinary symptoms. It can help with discomfort during sex in the menopausal transition. It is great treatment.

Virginia

Itchiness, dryness…

Mara

Exactly, yeah! So I was doing a list of causes of urinary incontinence: Another one is overactive bladder, which we often use oral medications to treat. That helps decrease bladder spasticity.

So this is all to say that it’s multifactorial. It’s rare that there’s sort of one specific issue. And it is possible that for some people, weight loss might help decrease symptoms. If somebody loses weight in their abdomen, it might put less pressure on the pelvic floor, and that might ease up. But it’s not the only treatment. So since we know that weight loss can be really challenging to maintain over time for many, many reasons, I think it’s important to offer our patients other treatment options. But I don’t want to discount the idea that it’s inherently unrelated. It’s possible that it’s one factor of many that contributes to urinary incontinence.

Virginia

This is, like, the drumbeat I want us to keep coming back to with all these issues. As you said, how would I treat this in a thin person? It is much easier to start using an estrogen cream—like you said, low risk, easy to use—and see if that helps, before you put yourself through some draconian diet plan to try to lose weight.

So for the doctor to start from this place of, “well, you’ve got excess abdominal fat, and that’s why you’re having this problem,” that’s such a shaming place to start when that’s very unlikely to be the full story or the full solution.

Mara

Totally. And pelvic PT is also underutilized and amazing. Everyone should get it after childbirth, but many people who’ve never had children might benefit from it, too.

Virginia

So the excerpt we just listened to is Dr. Mara talking about urinary incontinence. The listener's doctor was implying that it was because of their weight. And we were just getting into how many health issues, especially in perimenopause and menopause, you're gonna hear that explanation for. And that's just not always true, and even when weight is a factor, there are almost always other treatment options besides weight loss. 

Corinne

It also makes sense to me that this is the most shared epsiode, because I feel like menopause is such a hot topic right now.

Virginia

Oh, it is. And we will continue to see this theme as we talk about our most popular episodes.

Corinne

Oh, interesting, yes, for sure.

2. Episode With The Hi