From Postpartum to Postmenopause: The Conversations Women Need to Have

In this episode of Life Without Leaks, we're joined by Dr. Barbara Frank of Harvard Medical School and Brigham and Women’s Hospital, along with Alex Fennell, co-founder of Attn: Grace, an innovative manufacturer of incontinence products.

Together, we explore the realities of bladder leaks and pelvic floor health during pregnancy, postpartum recovery, perimenopause and menopause, and we discuss why more women are finally beginning to talk more openly about their experiences.

The conversation covers:
• The connection between hormones, menopause and bladder leaks
• Why pelvic floor therapy is having a major moment
• The surprising relationship between pelvic floor tension and incontinence
• How products can impact skin health, comfort and UTIs
• The truth about hormone replacement therapy
• Why community and conversation matter so much in women’s health

Alex also shares the story behind Attn: Grace and the company’s mission to create cleaner, plant-based incontinence products designed to support women with comfort, dignity and confidence.

Whether you’re navigating postpartum recovery, menopause symptoms or simply looking to better understand pelvic health, this episode offers expert insights, practical advice and an encouraging reminder that no one should feel alone in these experiences.

Links

• Attn: Grace - www.attngrace.com
• Attn: Grace Facebook
• Attn: Grace Instagram
• Attn: Grace Pinterest
• Attn: Grace TikTok
• The National Association for Continence - www.NAFC.org

Music
Rainbows Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0 License
http://creativecommons.org/licenses/by/3.0/

Attn: Grace pads and liners are ultra-soft, highly absorbent and made without fragrances, dyes or bleaches, so nothing comes between you and your comfort. They keep you dry, control odor and are gentle on sensitive skin, so you can move through your day with confidence.

Shop at attngrace.com and use code NAFC10 for $10 off your first order. Also available at select retailers nationwide.

Transcript

The following transcript was generated electronically. Please let us know if you see any transcribing errors and we'll get them corrected immediately. 

Bruce Kassover: Welcome to Life Without Leaks, a podcast by the National Association for Continence. NAFC is America's leading advocate for people with bladder and bowel conditions, with resources, connections to doctors, and a welcoming community of patients, physicians, and caregivers. All available at nafc.org. 

Welcome back to another episode of Life Without Leaks. So I'm your host, Bruce Kassover, and joining us as always is Sarah Jenkins, the executive Director for the National Association for Continence. Welcome, Sarah. 

Sarah Jenkins: Thanks Bruce. I'm really excited for this conversation. 

Bruce Kassover: I know... I am too because today's podcast is a little different than what we normally do. Typically it's just us talking with a guest about things and stuff. But today we actually have two guests and we're going to be talking about incontinence and its relationship to things like pregnancy and menopause and perimenopause and all that sort of stuff.

So today, joining us first is Dr. Barbara Frank. She's a faculty member at Harvard Medical School and a practicing doctor at Brigham and Women's Hospital in Boston, Massachusetts. And there she provides advanced care and gynecology from menarche to pregnancy, to menopause and beyond. So welcome, Dr. Frank. Thank you for joining us today. 

Dr. Frank: Thanks for having me. 

Bruce Kassover: Excellent. Also, joining us today is Alex Fennell. That might be a familiar name to some of our listeners because she's a friend of the podcast. She's the co-founder of Attn: Grace, which is a product manufacturer that's pretty distinct in the marketplace because they're committed to just producing the most natural products that they can make. No dyes, no parabens, no bleach, no fragrance, no latex, nothing but proven plant-based components to keep you dry. So welcome, Alex. Thank you for joining us. 

Alex Fennell: Hi, Bruce. Great to be here. 

Bruce Kassover: Long time since we've spoken; very excited to have you join us. So maybe you want to catch us up a little bit, tell us a little bit about yourself, about Attn: Grace, and what's been going on since we last spoke.

Alex Fennell: Sure. Okay. I will try to do that in fairly expeditious fashion because it's been a minute since we chatted, so there's been a probably a lot that's gone on. But, so I think high level, we, we started Attn: Grace back in 2020. And really the whole, as you guys know, but for your listeners is, as you guys know, our whole sort of thesis and reason for being was really wanting to come into the incontinence category and make the most, I think of it as like just the most natural product we possibly could without ever compromising on performance, because of course in this category you have to stay dry. The product has to work really well. So we looked for an opportunity to reimagine the incontinence pad to replace petroleum components where we could with plant-based components to leave out, we leave out, as you said, like all of the dyes, all of the synthetic fragrances, the bleaches and other sort of irritants that are sometimes part, or I shouldn't say sometimes are often part of the supply chain, with the sort of bigger box brands in this category. And the result happily has been a product that seems to make many women who struggle with leaks quite happy in the sense that they find the product super comfortable. They don't find them irritating to their skin. They keep them really dry.

So I'm really proud of what we've built. We're still very early on, always extending our line and looking for different ways to meet women who are living with leaks where they are, and figure out the best way to continue serving their needs in a more modern and thoughtful way.

Bruce Kassover: It's always fascinating to hear about innovation in a manufacturing industry in particular. And, the sorts of things that you're doing, I'm sure are really being received incredibly well by, by so many people. It's very cool to hear. 

Alex Fennell: Thank you. Yeah, it's nice. It's, I think, it's, we're far enough along in 2026 with sustainable innovation and all of the work that's been done around material science that you can now, you really can have a product that is heavily plant-based and still performs exceptionally well.

So it's kinda the best of both worlds, and you don't have to... there's really not any, there's not a trade off, as you might, as we might have been, like historically used to, like when we first started transitioning to natural period care and natural baby diapers, there was a bit of a learning curve and then, the products caught up and they now can perform at par with with, conventional products. And the same is happening now in the incontinence space, so it's really nice to be able to be providing women with a more natural alternative. 

Bruce Kassover: That is outstanding. And Dr. Frank, we have not met before this podcast and it's great to see you, so I appreciate you being here with us. Also, maybe you want to tell us a little bit about your background and how you got to be here today. 

Dr. Frank: So I'm excited always to talk about anything women's health, because talking about it is the first step. And what Attn: Grace has done is not just brought these products, which obviously is key because this, we need clean products, but it's talking about it. It's making a community that's going to speak up about something that was always poo-pooed to talk about. So many women don't even want to talk to their provider, their doctor about it. They're barely talking to their friends about it. They're walking around - were walking around - with like tissue paper and toilet paper in their underwear because they didn't want to buy the products.

It was embarrassing or even bringing it up was embarrassing. And and I want to talk about it and I want to talk about all of it. So that's how I got involved at the start. And Attn: Grace invited me to be an MD that could bring this, be part of this community that could answer questions and make this really accessible for a lot of women.

And I think that in my practice as I'm a general OB GYN here in Boston, I see, bladder leaking is not just the older ladies that are fully incontinent. We're talking about incontinence in the postpartum period. We're talking about incontinence surrounding perimenopause, and perimenopause is having its hot time right now. So there's just so much space to just talk about it and women are really starting to come forward and talk and I'm excited to be part of this brand and also in my practice like just speaking up and having this open space for women to talk about the weird and the uncomfortable, and that's why I'm here. 

Bruce Kassover: That's great to hear. And I'm really interested in particular, in your perspective as a physician, because I think a lot of us, when we think of physicians, so we think that the first thing that you get from a doctor is medicine. And maybe you would then have a procedure of some type, maybe it's, minimally invasive, it's a surgery or something.

But we're talking about products, so maybe you want to talk a little bit about the role that products play in the practice of medicine, from a doctor's perspective. 

Dr. Frank: Yes. I think that in medicine we've, there's two things that have, that I'm, we're hoping to get back to, at least in my practice I'm hoping to get back to, and one is prevention. And I think that what you, when you were just saying Bruce, of treatment, of medicine and surgery, doctors have - a lot of doctors, not all - are routinely into, "Okay, what can I give you to fix this?" And I think our society needs to move more towards prevention.

And so talking about it is the way to lead up to prevention. And so it may not become as big of a problem or maybe it staves off needing procedures. And I'm not saying you don't, there are definitely, with stress urinary incontinence, with anatomy, you can only do so much in PT and sometimes with other if you have other issues. So this is not an encatchment for everyone. But I think that prevention is key.

And B, and then on top of that having a product, products are important as a healthcare worker or as a doctor to provide to patients, because I see these women coming in who are using the wrong product and their skin is irritated and they're uncomfortable and they feel like it smells and they're big and bulky and, so having the right product and also products that - and one of the biggest things that I was so excited about with Attn: Grace was like skin protectors, and I joke with people like, you need to treat your bottom, like you treat your baby's bottom. Like you need to put all the emollient and all the, the bear... we call it barrier cream. And need to protect your bottom because if you do have incontinence and you don't necessarily, or you're not at the point where you want or need medicine or surgery, you need that, you need products that are going to work so that you can go on your run. You can go to the bounce class at the gym and not feel like you're going to drip all over the floor.

That doesn't mean you need surgery, there's no medicine for that, but there's good products that will protect you. 

Bruce Kassover: I like hearing that a lot. And you know what I'm wondering Alex, this is a chance for us to peek behind the curtain a little bit and talk about, how products do get developed to meet a particular need. As somebody who's on the manufacturing side, clearly you're working with, you're working with Dr. Frank, so you have a relationship to, with doctors and care providers. But how much of what you do is based on listening to what doctors are telling you, Hey, there's a need in the market?

Listening to what patients are telling you, Hey, I'd love to be able to hear this? Or coming up with ideas yourselves and saying, Hey, I bet that this would be a good way to, to address X, Y, or Z. How does that process work? 

Alex Fennell: Yeah, that's a great question. Barbara, I just want to say completely echo what you just said about raising the conversation, just to close that loop. It's so important. And Barbara was my doctor for a long time, you guys, full disclosure. And she she taught me the importance of not just being comfortable enough to advocate for yourself in different contexts. So I think that's just, that's definitely core to what we're hoping to do here, really, just break down, break down those barriers that prevent women from having those conversations. Because a good chat with your doctor can make all the difference.

So, in terms, I will speak to my experience, Bruce, which is, limited in the sense that I was a lawyer for a long time before this. Attn: Grace is my first experience being on the manufacturing side of things. For us, Mia and I, my co-founder, we really, like the whole genesis for this idea came out of a very personal, sort of organic experience. She was home having lunch with her mom, who was in her late eighties at the time.

And her mom was this just like fabulously put together, like really very sophisticated, very independent, getting her hair blown out, getting her nails done, living like just this very, a cultivated life and there she was that day coming out of the bathroom with her pull up diaper, let me say, and stuffing it in the sleeve of the newspaper bag. And Mia was really struck by how that just stood in such a stark juxtaposition to the rest of her mom's life.

And then as she dug in a little bit, she learned that her mom was really struggling with a lot of irritation from the pads that she was using, the pads or the pull-ups, whatever the case may be. And so to make a very, a much longer story short, our idea for our products that we sell today was really around solving that skin situation.

And really when you think about it, and people, hats off to the amazing entrepreneurs who revamped the period care space ahead of, ahead of this wave that we're going to start seeing now . Women with, when you have your period, you're wearing products, either in or against your most, some of your most like sensitive skin for 24 hours a day for, call it a week to 10 days. With incontinence, women are wearing these products often 24/7. And so we just saw a real opportunity to make that experience the consumer's experience, the experience of wearing a pad and living this sort of life where you're, where that pad is part of your every day as comfortable as possible. And for us, the approach we took was really just to try to find as many plant-based, as I was saying, like plant-based cleaner alternatives to chemical synthetics as we could without compromising on the absorbency.

Bruce Kassover: Clearly you're finding them and you're finding an audience and it's resonating with people. So maybe I want to talk a little bit about how you talk, figure out what products make sense for people at different life stages, because as you've been talking, we want to really get into a little bit about how people can address their symptoms and their conditions as they are getting towards the age of menopause, as they enter, into menopause and then beyond. So maybe you tell us a little bit about whether or not there are different products for different needs as you start to approach these various stages. 

Alex Fennell: There, I think there definitely are, and I think, depending on a woman's journey, it can, it can it can really change at different stages, so let me say, for me, we have four kids. It was four vaginal births. I wore a liner like I, our liners didn't exist at the time, so not ours, but back in 2018. But, I wore a light liner postpartum for a bit, and then I, knock on wood, haven't had any other issues since. I fully expect I will down the road. We have women who come to us their, CrossFit athletes or, they're doing high intensity training, marathon runners, that sort of thing. Maybe they're in their, midlife to perimenopause, menopause age. And I often see them slotting into our, either our hybrid pads that, we have, one pad that works really well for bladder leaks and period flow.

So you have women, who are in that stage of life where you're still getting your period, but you're also dealing with bladder leaks. The two might be really unpredictable. And so there are pads that, that can work well for that situation. And then it can, it really can evolve; for us, what we see anecdotally with our customers who are candidly wonderful about giving us feedback and talking about their experiences, so we've learned so much about this woman's experience with incontinence over the last few years. Typically as you get older, it does get, it can progress and so you move up the absorbency hierarchy. We've really tried to set up our product line almost as like a care system where she can come in and out as she needs and find a product that is just right for whatever her needs are at that time, if that answers your question. 

Bruce Kassover: That most certainly does. But it also brings up a question I want to ask Dr. Frank, which is, when you're working with a woman who is expecting, is one of the things that she is expecting that she may have to deal with leaks as part of the postpartum process, and if not, how do you bring her up to speed? 

Dr. Frank: Yeah, so bladder leaking happens as early as while you're pregnant. There's a couple reasons. One is your kidney function ramps up. You're trying to clean out clean out toxins faster so you're peeing more often. The anatomy changes, so the baby presses on the bladder and you leak a little bit, and that's just, that can just happen. So even in pregnancy with needing a aligner or something like that, is something I tell people that it's not uncommon that you're going to maybe have some leaks just from anatomical changes and physical changes. And then I don't, I let people know that immediately postpartum, specifically the first, like, week or two, incontinence rates can be pretty high.

And I promise them that will get better. 40% of women postpartum will experience leaks. 40%. So you're talking a huge amount. And granted, at that time they might be wearing a postpartum, I call 'em the postpartum granny panties, like at that point they're wearing, because they're catching blood and urine and such, but, and then by the time you get to six months postpartum, it's about 15% of people will , with issues with bladder leaking. So I like to explain to people that this is, it might happen to you. It's a very common occurrence, and there's products that we can use, but even more importantly, when we're talking about prevention, explaining the anatomy and taking the fear away from it of there are things you can do, pelvic floor physical therapy, which I know is not what we're talking about today, but all of that work is huge. And then on top of that, the hormonal shifts that happen postpartum are similar. I always tell people, postpartum your vagina's in menopause, especially while you're breastfeeding; that's like, the silly way to say it, because the estrogen levels are low, which is the same thing that happens in menopause. And when that happens, you are more likely to have leaks and the muscles aren't as elastic as they once were. So doing pelvic floor, physical therapy can help the recovery afterwards. And then having the right product postpartum and knowing what you're looking for, I think is really helpful in the education that I give a lot of education about with, in pregnancy and postpartum.

Alex Fennell: I'm curious. Are you seeing a shift in the last, I don't know, call it 10 years, like around women? Are your patients being more proactive about asking the, like, trickier questions? Is there, are you seeing a shift? 

Dr. Frank: Yeah. So all of the. All of the, I'm not, I don't have Instagram, like I don't do the Instagram TikTok stuff, but all of my patients tell me what they're targeted for and the number one targets are pelvic floor stuff right now. Huge push. Pelvic floor PT is like in its, in it's, like, hot moment, which I'm so excited about. And I actually just am, a woman in the south end who just, in my neighborhood, who just opened her own pelvic floor. She's been doing it for 10, 12 years. And everyone poo-pooed her like, "Why are you doing pelvic floor? You're never going to have any business."

And now she's this guru teaching everybody pelvic floor. Because it's, I don't know if everyone knows this, but the, when you do pelvic floor PT, it's uncomfortable. It's like internal vaginal exams. And so a lot of women would be like, "Whoa, like only my gynecologist is going to do that kind of maneuvering and whatnot," but with the right person and trust and all that stuff... but I, yes, so many people are doing it. It's all the hype right now. And even teaching. They're seeing people in the third trimester working on pushing, how to learn how to push, and then they're seeing them postpartum and they're bringing their babies like, come bring your baby. It's okay to have your baby there working on pelvic floor healing and prevention of incontinence and fixing the muscles. Huge ask, way more than ever. People are already, they are already tied into PT even before I see them sometimes and they're starting early. 

Alex Fennell: That's awesome. 

Dr. Frank: That's great. 

Bruce Kassover: I love hearing that, and I think that if there's anybody more excited, it's probably Sarah because I know that she has been leading a push for the longest time to try and really drive more appreciation for the work that the PTs do. Wouldn't you say Sarah? 

Sarah Jenkins: Yeah, absolutely. And that, having gone through PT myself after having a baby and discovering that I had a prolapse, I just, I know firsthand how valuable it can be and, it's a shame that it's not normally recommended to women after they have a baby. I think every woman really should go and be seen and just get, a baseline of, this is where you are and this is, what's going to maybe happen over the next year or so, but it doesn't, people don't always heal on their own. So I think it's really important to know what to do and to be able to know how to use your muscles to, to help repair yourself. It's super important. 

Dr. Frank: And I know this isn't in the space, this isn't in the space of postpartum, but you wouldn't believe how many women of all ages are diagnosed with overactive bladder interstitial cystitis, which is a fancy... "interstitial" means "bladder," "cyst" is, and "cyst" is "bladder" and "itis," inflammation. So it's like "bladder irritation and inflammation" that kind of is a catchall of "the bladder hurts and we don't know why. There's no infection, but it's inflamed," and you'd be, there's so many women that come in with leaking at even young ages or overactive bladder, they're going every few hours or they're always feeling like they have to go, and the actual, the culprit is something called "high tone pelvic floor dysfunction," so it's actually, you're not, it's going to blow your mind, but the pelvic floor is too tight. Which is crazy because we always think like it's too loose to make you leak. But when it's so tight, it's like having a muscle spasm in your back and you're frozen.

And these women are super tight, especially women that are big in exercise, CrossFit and spinning and running, or even with where we hold our anxiety, like a lot of women hold their emotions in their pelvic floor. I know that's crazy to think of. We think about our gut holding emotion, but I see it in the pelvic floor.

And that can cause incontinence and leaking. And I get so many women who come in and say, "I've been seeing doctors for years. They tell me I have chronic UTIs. They tell me I have IC, or interstitial cystitis." And it turns out that it's just this, and they're leaking. And it turns out that this pelvic floor is tight and all it is a little PT to help you get that spasm out. And and we have a lot of success preventing leaks that way. 

Sarah Jenkins: Yeah I think that is so important to mention because it's drilled into our brains that Kegels are the answer and that everyone should be doing Kegels to strengthen your pelvic floor. But that was my problem as well. It's like you are already so tight that to be able to contract your muscles to prevent a leak is almost impossible. You can't, they can't contract anymore. Knowing how to relax the pelvic floor is just as important. 

Alex Fennell: Not enough people understand that.

Dr. Frank: And also pain, it's in dyspareunia, which is the fancy word for, like, pain with intercourse. There's just so, you can have pain with bowel movements because of it. There's just so much, tight pelvic floor that yeah, nobody really knows about it.

Alex Fennell: It is remarkable that we've been pushing babies out of this part of our body for centuries and of course it's a rather traumatic, physically traumatic experience. It seems rather logical that we should be paying more attention to it. 

Bruce Kassover: Yeah. I have to say it does seem like it's tough to be a woman for a lot of reasons. And this is just part of it. Speaking of part of some of the challenges of being a woman is ,that as you get older, you start to move towards menopause. And I'm wondering if you can talk a little bit about the changes that you're going through then, what sort of is happening and how that might manifest itself in incontinence symptoms also. 

Dr. Frank: So in menopause, the what's happening is your estrogen levels, your hormone levels are dropping, estrogen, progesterone.

Specifically what estrogen does is it decreases the blood flow to the tissue surrounding the vagina, surrounding the urethra. The progesterone drop as well as estrogen decrease this like elasticity of the vagina and the muscles over time, and it's, so, as you get, as we age, we think about gravity, our muscles aren't, as we've been carrying our insides in this hammock for however, for 50-something years, and your muscles are weaker. Also, testosterone levels dropping. That is, part of like muscle tone. And then this, your kidney function changes with low estrogen levels. So your, the flow through the kidneys is changing and the ability to stop peeing because we think of like younger women with stress urinary incontinence, which is, like, cough, sneeze, leak. And then as you age perimenopause, menopause, it becomes more of a common, what's called, like, mixed incontinence, which is, like, the overactive bladder, gotta go, like, the key in the door, you can't get their fats enough. Along with the stress incontinence. So there's hormones happening, and then with age, all of these, like, changes with musculature and just the strength that changed. And, Alex, what you had said before about or talked about, like, why it's getting its kind of highlight right now is, you have to remember, 50, 75 years ago, this wasn't really a discussion for multiple reasons.

One is, women were having babies in their twenties, so they weren't, their pelvic floor wasn't having as much... at that, point you didn't have the years behind you. And then people weren't living to the eighties, so they, we weren't having, it wasn't happening as much.

So I think that because we have this ability to be alive longer, women are stepping up and saying they want better quality of life. And I think that's why it's, it's getting its moment now.

Bruce Kassover: The length of time that people go through these changes is pretty considerable. Perimenopause can last a while and then now also, speaking of which, tell me if I'm crazy, but I'm also under the impression that menopause itself doesn't actually exist. In the sense that, it's a threshold. You have perimenopause for a certain period of time, and then after you haven't had a period for 12 months, that's like the point of menopause. But then immediately you are now postmenopausal. So that rather than being a stage that you exist in, it's something that you pass through. Is that a correct understanding? 

Dr. Frank: Yeah, and perimenopause we've discussed is the 10 years before that. So it's like this big guess and it doesn't all happen in, a hundred percent, Bruce. It is totally a spectrum and it goes like this, because you'll have women who are perimenopausal, and they might have three or four months with no period. So their estrogen is like down here and they're feeling it, and they're having the hot flashes, they're having all the symptoms, and then one egg comes to life, poof, it ovulates, and now you've got some estrogen and you're back at the starting point again.

But you just had three months of menopausal symptoms. And then you're like, wait, this doesn't count as menopause. So it's a, it's this like 15-year journey, which is a really long time. 

Bruce Kassover: And the list of symptoms that people experience is crazy. It's not just, hot flashes is what we all know, but there's like 35 other different things that that women can be going through as part of this isn't it? 

Dr. Frank: People are telling me their ears are itching. Like I, that itchy ears is a thing. And I had a patient who went to see the cardiologist because she was having palpitations and was almost about to go get a cardiac ablation. We started estrogen and her palpitations went away. 

Alex Fennell: Oh my goodness. 

Dr. Frank: It's, there's, so, the hormones, the estrogen... we need estrogen. If we're going to live longer, we need estrogen. 

Alex Fennell: Can we dedicate 30 seconds of this podcast to dispelling the myth about HRT?

Dr. Frank: Oh my goodness. I don't know if we have time for that. 

Bruce Kassover: No, Alex, that's a great point. There, there are so many fears that are out there about, about HRT and people are, like, deathly afraid to consider it. Yeah. Maybe you could talk or maybe Dr. Frank, you could talk a little bit about the reality behind it.

Dr. Frank: Yeah, so I, I think it's so interesting because people come and ask for birth control pills. And guess what? Birth control pills are actually hormone replacement therapy. Like, they're the exact same hormones. They're just dosed a little bit differently and the estrogen is like different place in the pathway. But people will go and get their birth control pill and there is a risk when you're on birth control of getting a blood clot, a DVT, like the blood clot in your leg or a stroke, and I feel like nobody thinks about that. Like we put all our, all the girls in high school, college, it's here's your birth control pill and there's risk.

But what happened is in the women's health study in the eighties was a, or seventies, eighties, was a large study of women on hormone replacement therapy, traditional hormone replacement therapy. However, most of these women started HRT beyond 10 years from when they went through menopause.

And what we know is the safest time to start is not when you have had nothing for 10 years, because now you're going from no estrogen to a spike in estrogen. So the best thing to do is in this transition somewhere between, I mean everyone's different, but, like, 45 to 55, there's our 10 years, right, is you onboard a dose that works with people's symptoms.

And so what we realized is in these, in this women health studies, they actually stopped the study early because women had strokes, and they were like "Too many women are having strokes. We're going to end this study." And it really was because they were studying women that were much older, had no estrogen for a long time and then they introduced estrogen. So now all those black box warnings have been removed. And I counsel my patients that, yes, if you have your, a personal history of breast cancer or a strong family history of breast cancer that you may not want to take, you're not going to take the risk because there is a slightly elevated risk.

And then blood clot and stroke is a risk, but it is incredibly low. And, and I quote people like less than 1% unless you have some other, you know, other issues. But then the benefits that we're seeing are just like so massive. And I, and the verdict's still out on all of them. We know that it's cardiac protective. We know it's muscle protective. We know quality of life people feel better with all of those like symptoms that we talk about, brain fog and all those things. But even like colon cancer prevention, there's so many preventers, things that are going to get better with this, and the, and all the data on dementia, which isn't fully there yet, but there's a lot of data coming out about menopause and dementia or estrogen replacement.

So I think the fear is dropping away. And we teach, you want to give the lowest dose for as short a period as possible. Although I tell women that I'm happy to keep you on estrogen forever. But there, yes, it, there is a risk, but it's not as scary as those studies were. And I say you took that risk when you got pregnant, because your estrogen levels when you were pregnant were through the roof. And everyone, no one signs a waiver when they get pregnant to say how much increased risk you're going to have of stroke and blood clot... that increases in high hormone states much, much more than HRT would.

Bruce Kassover: That's very encouraging to hear. I'm wondering, because, you mentioned birth control pills, how is HRT typically delivered? Is it, is it pill? Is it cream? Is it, how do women typically take advantage of it? 

Dr. Frank: Yes and yes, 

Alex Fennell: Right? 

Dr. Frank: Yes, yes and yes. There's everything. You what, in the spray? Yeah, there's spray, there's cream, right? When you think of estrogen or hormone replacement, there's two ways: there's systemic, so you're talking about all the things, all the symptoms. And then there's local estrogen, which is just for for the atrophic vaginitis, which is the menopause atrophy in the vagina.

So there's local estrogen, which can be a cream, a tab, or a ring. And that is just for local. And even if you have a plug for this, even if you have a history. Of a personal history of breast cancer, you're being treated for breast cancer, you can use vaginal estrogen. It does not get absorbed systemically. Everyone can use it. It helps with incontinence, helps with painful sex, helps with pelvic floor so everyone can be on vaginal estrogen with no risk. The other one, the oral or systemic can be done as a tablet. It can be done what you take orally. It can be done as a patch. It can be done as a spray, as a gel. And then some compounding pharmacies. I don't practice this in my own practice, but there are plenty of places that do in, like, inserts, they look like little rods. And they go under your skin. So there are a bajillion, literally, different ways to do this. Whether you do compounding, whether you do what your insurance will cover, that's FDA approved.

There's many different options and you should talk to a provider physician or a mid-level provider that can give you all of those options. And a lot of times, Bruce, the decision to do it is based on what you're comfortable with. Can you remember to take a pill every day? Do you prefer all in one patch and then you set it and forget it?

Are... how do you want to play around with the doses? It's not a one-size-fits-all, and I tell people we might change three different times before you find what you like. 

Bruce Kassover: That's very cool to hear. And you mentioned something about moving people off of it . How does it typically work? It's it's not something that you would just go on forever for the most part. How does the dosing and the tapering off work then? 

Dr. Frank: Yeah. Historically the teaching was, you come, every year or two you try to wean down or wean off and see how you feel.

Most women after anywhere from three to five years post-menopausal, they're not getting the hot flashes anymore. And a lot of women who've never used hormones, you realize are doing okay. Like they're out there living their lives. They didn't know any differently and they got through this menopausal transition.

So we used to, historically, every year or two I would wean people down and off and see how they felt. And then there'd be some women who were like, I'm taking that for the rest of my life. And they show up to me in their eighties and they've been doing it, for 30 years and I don't stop it. But now that we're getting a lot of data on it being so great in for other things, I'm finding a lot of women just wanting to stay on it.

Bruce Kassover: That makes a lot of sense. And Alex, I'm sure that it's something that you're very interested in hearing because you guys do, are so careful to try and make products that are not hormone disruptive and that really will work without making any type of interference with whatever people are taking. A lot of people are concerned about the actual, the chemicals and the composition of the things, especially things that are used so intimately- maybe you want to share a little bit with us about that and what makes your products distinct in the marketplace also.

Alex Fennell: I think this kind of takes us back a little bit to one of the founding principles of Attn: Grace, and it really started with the notion that we didn't think that you needed to accept this sort of like inherent trade-off that the category has seemed to assume. In other words, like that you have to have... in order to have a high-performing pad, you have to use petroleum-based plastics, you need synthetic fragrance to cover up odor, you need dyes. And, there's been... I feel it, it was our perspective that the industry has, I don't know, stayed stagnant in that sense, and we really wanted to take everything back to a material level and really look at the products in terms of what the users experience and especially when you think about the fact that women are wearing these products for often extended periods of time.

So we really went back to deconstructing the pads and looking at all of the different materials that were... that are used in the construction. And we use a plant-based top sheet instead of a petroleum-based top sheet. We use sustainably forested tree pulp instead of conventional tree pulp.

All of our materials are processed without using chlorine bleach. We chose our European manufacturing partners really specifically because of the high standards that manufacturing in Europe is held to. Our European facilities are held to EU chemical safety standards, which are quite different and materially, I would say, materially more restrictive than US law requires.

And then we take it one step further, and we're really meticulous about making sure that we're... our products are evaluated independently by third parties. So we have Dermatest certification, which means our products are clinically tested and dermatologically approved for use on sensitive skin.

We have the Oeko-Tex standard, which basically means that every material that goes into our products are independently evaluated over, hundreds of different regulatory standards. And then we're also really proud..., you hear a lot of talk these days about PFAS these sort of 'forever' chemicals.

And it's a really complex topic, so to try to sort of synthesize it here, PFAS are... it's a very nuanced conversation in the sense that they're everywhere, right? They're in the rainwater, they're in our groundwater, they're in the air. And I read a really startling statistic at one point recently that says they're in something like ninety-seven percent of Americans' blood stream.

So you really... none of us can guarantee that there's never going to be a single molecule of a PFAS somewhere in our global supply chain and I think anyone who makes that claim is probably overstating. But what we are really proud to stand behind is that we very intentionally make sure that we don't add any PFAS into our supply chain.

And that, for us that's a big, that's a big distinction, especially again, as you're dealing with a product that's so close to your intimate skin and that you're wearing every day .

Bruce Kassover: I'm pretty sure that's gonna resonate very strongly with a lot of people. There's an enormous amount of concern about, chemicals like this and what they may d- may be doing to us, what we don't realize yet that they're doing to us. So that's- Yeah ... gotta be very reassuring. But, I'm the sort of person who, I like watch videos on, like, how tennis balls are made. I just I find that, that sort of, the actual manufacturing process very interesting. So maybe so I really would like to hear a little bit more about plant-based materials. We know that petroleum produces plastics and all that sort of stuff that's everywhere.

And so we have, dead, prehistoric organisms all, all around us still. But what... when you talk about being made from plant material, what is that like? What sort of plants are we talking about? How does that work? Because I th- I just think it's a cool process.

Alex Fennell: Yeah. No, it's super cool. I always love chatting with people who are into this stuff. So we... I'll share a quick anecdote. When we first came up with the concept for Attn: Grace and we were starting to research and understand the category, we had seen what had happened in the period care space and the incredible innovation that you've seen with the period brands that have come in and replaced petroleum-based materials with cotton. Right? So you've got tons and tons of brands out there who are providing plant-based period products for their customers. And we thought, "Oh, okay. That would make a lot of sense here." And fortunately, for our sake we had a wonderful advisor on our team early days.

And she's just, she's been in the nonwoven space for 30 years, and she had taken us under her wing and she said, "Oh, you guys, like, no, you can't use cotton for bladder leaks. It works great for blood. It doesn't work for urine the same way." And of course, when you think about the difference in viscosity and the flow and all of that, it, it makes a lot of sense.

But that, we hadn't realized that. And so we went back to the drawing board. And where we ended up after, a fair amount of research and development, we ended up using, It's up- it's called upcycled sugarcane waste to make plant-based polyethylene. So it is still technically a plastic, but it is derived from upcycled sugarcane waste.

And so there are two things I think that come from that are super relevant for customers or, for end users, let me say. One is that, because it's a hybrid material, because it's still plant- it's plant-based and it still contains polyethylene, it's really high performing, so it wicks the moisture from a leak incredibly quickly and really well, so it keeps you super dry and comfortable.

But at the same time, the only materials that are actually touching your skin are 100% upcycled sugarcane fibers, so fully plant-based materials that are coming into contact with your skin. And that sort of leads to I, I think, a much better user experience in terms of comfort, but doesn't compromise at all on the absorption or the moisture wicking that you need to have to have a really effective bladder leak pad.

Dr. Frank: And even with the creation, and I remember sitting with you, I was like talking about this product when it was like in its fetus stage in your mind and saying to you that even with all the clean, no matter what you do, if you're just like a clean diaper, just like clean tampons, clean whatever, it, no matter what it is, there's friction and it's rubbing the tissue.

And you if you are wearing a daily pad, I don't care what age you are, because there's young, there's some women who just don't want any don't like discharge, don't like whatever. If you are wearing a chronic pad, no matter how clean it is, your skin is going to be irritated. And so creating some sort of barrier was always like, I remember saying to you like, "I'm in it for the pads, but I was really in it for great barrier cream that came with the product" and we really push, right? 

Alex Fennell: Yeah. No, and we do, we our barrier cream is awesome, Bruce, and it's, 100% natural, which is really nice. I, that just took that memory, took me back. 

Dr. Frank: I was like if, because no matter how great you make a pad, you have to protect the skin. And as you're postmenopausal and your estrogen, again is down - we talked about this in the postpartum time - when the estrogen is down, the vaginal skin and tissue is really irritable and not elastic and itchy and dry. And if you don't moisturize and protect, you are going to have yeast infections, bacterial infections, rashes, discomfort, incontinence .

Alex Fennell: Yeah, we see a lot of overlap between like women figuring out that their, either their pad isn't drying fast enough, or they're not changing it frequently enough and or they're not using a barrier cream and they're having increased UTIs, and it takes a long time because you, it would not be intuitive to me, even with my role, necessarily, to connect UTIs to your menstrual pads or your incontinence pads or what have you. But when they start changing more frequently or using a cream or switching to a different product, the UTIs often diminish. And that was, that was really surprising to me.

Bruce Kassover: It would be a very important message to a lot of our listeners. We know that whenever we talk about UTIs, that really gets people paying attention because that's just, it's something that's the front of everybody's mind. And I'm wondering, what is the relationship between UTIs, not just in, potentially product use or pads and things like that, but with, going through the perimenopause and postmenopausal process. Are UTIs more common than just because of the changes your body's going through also? Or is it just something that, you know, you happen to be using some products and having some issues, so it's not a surprise that they go hand in hand?

Dr. Frank: It's all it is again, multifactorial and all of it. I think the first thing is that you have to be sure that what it is actual infection. So I think one of the big fallacies that happens is people are like, "I have chronic or recurrent UTIs," and they're getting irritation somewhere, and then they're calling their provider and their provider is giving them an antibiotic and they're just treating it and they're like, "I have chronic UTIs."

You have to prove it to me. I make you come in and leave a sample. I want to see what the bacteria is, I want to see what it's responsive to, and I want to see that you're actually having UTIs because maybe you're irritated because your skin is dry down there. Maybe you're irritated because you're in perimenopause, menopause and your estrogen level, which we talked about before, as they drop, make the skin less, have less moisture, have less elasticity. So first of all, make sure that it is a urinary tract infection, and also the pelvic floor stuff that we talked about with Sarah, too, is that the... that if you have a really tight pelvic floor and it's irritation, it's cystitis, not a urinary tract infection, we need to tease all of that out.

But, yes, infections increase with, in postmenopausal status, and it is typically because of estrogen and the decrease in estrogen, as well as if you are using products that are irritating to you or irritating to your bottom, that can also increase the risk. 

Bruce Kassover: That makes perfect sense. And I guess the biggest challenge is going to be getting people who to say, "Okay, it's time to go into the doctor and deal with this. And even though I'm not comfortable doing that," and that sort of brings up another point as well, which is, you're probably dealing with a lot of people who didn't realize that they're going to be experiencing these symptoms, whether it's UTIs or bladder leaks and things like that. Maybe you could talk a little bit about how people process that from a mental health perspective. How they feel about themselves and their future and the sort of role that as a physician that you can play to help them get into a better frame of mind.

Dr. Frank: Yeah, I think that talking about it and seeing the community, Attn: Grace having their blog, having their community, having their posts where people can talk to each other, you don't feel alone. And when you don't feel alone in anything, humans, our brains work in community. And it doesn't matter what the community is; when you have a community, especially when you're having a problem, you're not alone. And when you're not alone, you're willing to talk about it, ask questions, and it feels less daunting. And even if I say to people, even if we can't fix it a hundred percent, at least we can try because we're talking about it.

That's the biggest thing for women is, talk about what's bothering you. I ask the hard questions. Find someone that asks the hard questions and that can direct you in the right way for, even if we can't always fix everything, but we can definitely make you feel not alone, and try. We have a lot of tricks up our sleeves to try. 

Bruce Kassover: I love hearing you say that; it's something, that the idea of community is something that we believe in very strongly at NAFC as well. If people are familiar with the website, they'll see we have a whole, a message board area where people, patients, caregivers, physicians can, ask questions and share tips and advice and, I like how you were referring also to the Attn: Grace blog and the sort of community that, that you have going on there as well. Alex, maybe could you tell us a little bit about how people can find Attn: Grace, what they can find online about the blogs and other things that you have going on to educate them about your products, but also the community that you guys are building?

Alex Fennell: Yeah, sure. I would love to. So I think, just building off of what Barbara was saying, when - and going back to the very beginnings of building this brand, I think - it was equal parts, like, wanting to deliver not just a better product, but also just a better experience for women living with this condition.

Especially women living with it, day in and day out. And so building a sense of community around it has always been something that was core to what we wanted to do. I'm smiling a little bit now because I can't tell you how many people, when we were out pitching to raise our first round of funds to get the company off the ground, how many people looked at us, "What are you talking about? Build community around incontinence? Like how is that even, what does that even mean? Like, how does that even happen?" I think you guys can probably relate to building NAFC against a similar backdrop. And so for me it was, it was always a welcome challenge.

Okay, like how are we going to do this? How are we going to bring women together around what is typically a very taboo and deeply personal topic? I think we're still just getting started, but so far we've built an enormous library of resources on our website from blog posts to a directory of providers that women can go and search with their zip code.

Or you can find pelvic floor therapists. You can look up OBGYNs, you can find urogynecologists, which, who knew that was a thing? But, combining the specialties of urology with gynecology. So there's that level that exists on our website. We're doing a ton of partnerships both in the postpartum space and in just the larger incontinence space.

If you follow us on social, which I would love for everyone to do, we're on, we're on Instagram and, and you'll see, we just launched a collaboration with Becs Gentry. She's a fantastic Peloton instructor and amazing athlete, a new mom. And we're so excited to be working with her to do exactly what we're saying, to normalize this conversation.

And it's, as Barbara was saying, it's not just women in their seventies, eighties, or nineties who are dealing with leaks. It's women from all walks of life and ages and stages. So those are the ways that we're showing up so far. But it's always evolving and we're always looking for ideas and partners. If anyone's listening and has any ideas, feel free to reach out. 

Bruce Kassover: That is so cool to hear. I love it. And I love things like the collaboration, all the stuff you have going on. What is the URL for the website again? 

Alex Fennell: It is ATTN Grace, G-R-A-C-E.com. 

Bruce Kassover: Excellent. We are going to put links to the website and your socials in the show notes so people can find you and certainly encourage everybody to go take a look see what you have and participate and join and, find not just the products, but find the support that's going to help you have a better experience as you address these things.

But this is Life Without Leaks. And one of the things we always like to do before we go is leave our guests one little hint, tip, strategy, bit of advice to help them live a life without leaks. Alex, I'm wondering if maybe you have one you could share with us today. 

Alex Fennell: Can I share two? 

Bruce Kassover: You could share as many as you like.

Alex Fennell: Okay. I'll share two. First, I think first and foremost, find a doctor that you can trust and be honest with which is an appropriate thing for me to say because like I said, Barbara and I go way back to when she was my doctor and guided me through some pretty tricky things.

So doctors are amazing, and if you can break through that initial hurdle of having whatever the conversation is, that might be a little bit trickier to have... I think it's always going to be worth it.

Then I think it's super important to find a product or a solution that works for you and that keeps you comfortable. The best thing about building Attn: Grace so far for me, is meeting all these different women who are, come to us and say, "I'm finally like, socializing again. I'm sleeping better, I'm working out more. I'm doing all these things that I wasn't feeling comfortable enough to do before." And so finding a way to manage your incontinence that allows you to live your life as fully as possible. 

Bruce Kassover: That has to be very rewarding to get that sort of feedback. I'm sure that it really means an enormous amount to you. 

Alex Fennell: Yeah, it's very cool. 

Bruce Kassover: Excellent . Dr. Frank, same thing goes for you, Life Without Leaks.

Dr. Frank: So life without leaks. 

Bruce Kassover: You bet. Do you have a hint or a tip for our listeners? 

Dr. Frank: Yeah. I think everyone is going to have a leak at some point. So to say it's going to be without leaks forever is me lying to you a little bit. But I think that talking about it early and often, I'll say it again, talking about it early and often the moment it becomes a problem and realizing that there is a community is how you're going to live a full life with or without leaks. So find the community, speak up, and even if you are going to, it doesn't get fixed a hundred percent, at least you won't be alone. 

Bruce Kassover: That is excellent. I love hearing that. We spend so much, realistically if NAFC did nothing but just help eliminate the stigma associated with these conditions, they be doing more than needs to be done. That's absolutely the biggest challenge that we see out there. And hopefully people listen to you and take that to heart and actually go see people who can make a difference for them. So thank you so much for sharing that. We really appreciate both you and Alex joining us today. And we certainly hope that listeners go check out Attn: Grace, take your advice to heart, find out about things like HRT and learn a little bit more about the changes they're going through in perimenopause as they enter into menopause and beyond. So thank you. It really means an enormous amount. 

Dr. Frank: You're welcome. Thanks.

Bruce Kassover: Life Without Leaks has been brought to you by the National Association for Continence. Our music is Rainbows by Kevin McLeod. More information about NAFC is available online at nafc.org.