Fiona Healy -Women's Health Physiotherapist

13/03/2024

Mairead has a wealth of knowledge on breastfeeding so these appointments could really help a breastfeeding mum.

Appointments available.
Pm / Text for extra Information.

Please share this post with your friends as I have daily slots available over the next few weeks.

08/02/2024

✅Women experiencing pelvic floor dysfunction (PFD). If you suffer from pelvic floor dysfunction with symptoms such as incontinence, overactive bladder, pelvic organ prolapse, pelvic pain, dyspareunia or vaginismus, Anú is for you.

✅ Women with pelvic floor overactivity. If your pelvic floor is tight and you would like to rebalance your pelvic floor as well as other muscle groups in your body, Anú is for you.

✅Busy women. If your life is already hectic and you have limited time available to train or go to classes, Anú is for you.

✅Women who want to regain strength after birth. If you have had one or multiple pregnancies and feel that you need to increase your pelvic floor and bodily strength, this Anú is for you.

✅Women who are peri-menopausal, menopausal or post-menopausal. If you are approaching, experiencing or past your menopause and feel that you have diminished pelvic floor function, Anú is for you.

04/02/2024

World Cancer Day

Preventive care is the best way to keep illness at bay, and detecting health issues early can offer better treatment options when they are most effective.

We’ve put together a list of vital cancer screening recommendations for females to help you take charge of your health.

✅Skin cancer screenings

Checking yourself for moles and having your skin examined by a medical professional can help detect many skin cancers early, when they are easier to treat.

Annual dermatology exams are especially important for people who are at a greater risk including those with:
• Skin that freckles or burns easily
• History of sunburn or prolonged sun exposure
• Certain types of moles
• Blue or green eyes
• Red or blonde hair
• Family history of skin cancer
• Indoor tanning habits

✅Smear Test

Cervical cancer screenings can identify cell changes in a woman’s cervix that can potentially lead to cancer.

✅Checking your breasts

It is important to be breast aware. This means knowing what is normal for you, so you’ll notice any unusual changes.

You should check your breasts at least once a month.

📍How to check your breasts
Look for any changes. Use a mirror to check your breasts from different angles.
Feel for any changes. An easy way of feeling your breasts is in the bath or shower. You can also feel for changes while lying down.

✅Mammograms

One in eight women will be diagnosed with breast cancer in her lifetime. Starting at age 50, annual mammograms are recommended for women of average risk.

Signs and symptoms of breast cancer include:
• A lump or hard knot
• A sunken ni**le
• Pain
• Redness or scaling of the ni**le area
• Swelling in the chest area
• Unexpected discharge coming from the ni**le



Talk to your doctor about your individual risk factors for all types of cancer and don’t forget to schedule your annual well-woman visit with your health care provider.

01/02/2024

Lá Fhéile Bríde

In Ireland, 1 February marks the beginning of spring and the celebration of Lá Fhéile Bríde, St Brigid’s Day.

The day has long symbolised hope, renewal and the feminine.

Making Brigid’s Day a national holiday is a true reflection of today’s progressive, inclusive Ireland, sending a strong egalitarian message to the world.

30/01/2024

Estrogen has a dramatic effect on musculoskeletal function.

Beyond the known relationship between estrogen and bone, it directly affects the structure and function of other musculoskeletal tissues such as muscle, tendon, and ligament.

Oestrogen is an anabolic hormone, which means it promotes muscle growth.
It is easier to build and maintain lean mass when levels are high.
Oestrogen acts to generate a fast strong muscle contraction.

It also supports mitochondrial function and has an anti-inflammatory effect.

This is one of the reasons that women in midlife may find it difficult to gain or keep muscle mass.

When oestrogen is low we need to work harder at the anti-inflammatory lifestyle.

25/01/2024

Cervical cancer is a cancer of the cervix (the neck of the womb).

It happens when cells in the cervix become abnormal and change slowly over time. Abnormal cells are sometimes called pre-cancerous cells. They are caused by the human papillomavirus (HPV).

You can reduce your risk of cervical cancer by:
• having regular cervical screening tests to pick up any early cell changes
• quitting smoking
• getting the HPV vaccine at school - the vaccine is most effective in young people between 9 and 15 years old
• talking to your GP about any concerns or symptoms

⚠️Symptoms
Cervical cancer often has no symptoms in its early stages.
The most common symptom as it develops is abnormal bleeding.

⚠️Contact your GP if you have abnormal abdominal bleeding.

Abnormal bleeding can include:
• irregular vaginal bleeding
• bleeding between periods
• vaginal spotting or unusual discharge
• bleeding when you have gone through the menopause (post-menopausal bleeding)
• bleeding after s*x

These symptoms are usually caused by other conditions. They do not always mean you have cervical cancer.

Less common symptoms as it develops can include:
• a pain in your pelvis (anywhere between your bellybutton and the tops of your thighs)
• pain during s*x
Even if you have had a recent normal screening result, never ignore symptoms

✅Cervical screening
Attending regular cervical screening is one of the best ways to protect yourself from cervical cancer.
A cervical screening test used to be called a smear test. This was before Ireland changed to HPV cervical screening.
Anyone with a cervix between the age of 25 and 65 should go for regular cervical screening when it’s due.

Are you up to date with your smear tests???

23/01/2024

The Mammi Study in trinity College Dublin is the largest study in Ireland to focus on Maternal Health.

Here are some of their findings:

Incontinence:
23.1% experienced stress urinary incontinence before pregnancy, 33.9% during pregnancy, 51.7% three months after the birth of their first child, 40.9% six months postpartum, and 41.2% a year postpartum.


Sexual health
Sexual health problems, such as painful s*x, changes in libido, vaginal dryness etc., are common during and after pregnancy. Among MAMMI study participants, 21.2% experienced painful in*******se before pregnancy, 14.7% during pregnancy, 43.4% three months after the birth of their first child, 30.1% six months postpartum, and 18.3% a year postpartum.

Pelvic Pain
Pelvic Gridle Pain (PGP) is defined as pain experienced at the back of the pelvis (buttock area, sacroiliac joints) and/or at the front of the pelvis (p***c symphysis). Among MAMMI study participants 68.8% during pregnancy, 51.2% three months after the birth of their first child, 40.5% six months postpartum, and 33.3% a year postpartum. Women with persistent PGP after the birth said they don't feel back to normal but that they put up with the pain. They had not expected their symptoms to persist after the birth and were uncertain about how their symptoms would progress.

Mental Health
Depressive symptoms are common during and after pregnancy. Among MAMMI study participants, 9.3% experienced depressive symptoms before pregnancy, 12.2% during pregnancy, 17.7% three months after the birth of their first child, 13.4% six months postpartum, and 12.8% a year postpartum.
5.1% of women experienced anxiety before becoming pregnant, 4.4% during pregnancy, 12.1% three months postpartum, 10.5% six months postpartum, and 11.6% a year after the birth of their first child.

One of the main findings is that women felt that they were not asked about these symptoms by their health care providers.

Women need better support around their pregnancy and postnatal recovery period.

18/01/2024

Prevalence rates of upper back, lower back, and pelvic girdle pain postpartum were 43%, 52%, and 41%, respectively.

Dunn G, Egger MJ, Shaw JM, et al. Trajectories of lower back, upper back, and pelvic girdle pain during pregnancy and early postpartum in primiparous women. Women’s Health. 2019;15. doi:10.1177/1745506519842757

There are so many reasons why women experience low back pain after pregnancy. The demands of looking after a newborn, all that extra laundry, the extra sitting and the hormonal as well as physical changes in pregnancy.

Muscles are challenged in pregnancy and after birth most women will need rehab to get back feeling strong again.

In The Postnatal Pilates Programme our Level 1 videos are ideal for women experiencing back pain after birth. We have a lovely stretch sequence and some core activation videos which will set you up for a stronger back in no time.

*xercises

16/01/2024

Notice how they sling from your coccyx (tailbone) at the back, to your p***c bone at the front and out to your ischial tuberosities (sitting bones) on the sides.

People tend to see them as tiny muscles, but they span the whole underneath of the pelvis.

They are muscles! And like any other muscles in the body that you might be more familiar with they can be weak, tight, strong, or lengthened.

They may be painful or be in spasm.

You might not feel like you can squeeze them properly.

You might be able to squeeze them but not sure if you can hold them properly.

You might not feel anything happening down there.

This is a reality for many, but it does not have to be. A pelvic floor physiotherapist can help you with this.

12/01/2024

1. Your body will feel fantastic.

Looking after a newborn baby (and other toddlers) is physically and mentally demanding. Upper back, mid back, lower back and hip pain are common complaints I hear from new mums. Pilates is fantastic to manage these types of pain as you move your body in lots of different ways that lubricate your joints and get the blood flowing.
Committing to rolling out your mat for 15-20 mins most days you will feel the benefits.

2. You will strengthen your tummy muscles

Pregnancy can take its toll on your tummy muscles. Diastasis Recti or tummy muscle separation is common after birth and pilates is perfect for rehabilitating this.

3. Your pelvic floor will get stronger

While Kegels are great, there are lots more you can do to strengthen your pelvic floor after birth. Research has shown that strengthening your hip muscles will have carryover into the pelvic floor. Improving the coordination between your pelvic floor and tummy muscles will significantly improve pelvic floor performance.

4. Your back will improve

Caring for a baby often means spending a lot of time still and leaning over, not to mention the weight of carrying them around.
Pilates will help you mobilise the stiff parts, and also help you regain core strength to help protect your back.

5. It is safe

While we all want to get back to exercise and the gym after baby, the return to running guidelines released in 2019 recommend waiting for 12 weeks prior to returning to running or high-impact exercise.
Of course, this does not mean that you lie around and do nothing for 12 weeks. Low-impact exercises are great during this time to build back up your foundation for a return to more strenuous exercise. Pilates is an ideal form of low-impact exercise.


6. You will reconnect to your core and body

Your body has changed hugely. You may be overwhelmed by having to care for a new human. After birth, your body may not feel like your own. It feels different, it moves differently leaving you feeling totally disconnected from it. Pilates is based on mindful movement thus connecting your brain and body.

09/01/2024

Let’s talk early C-section Recovery Tips.

✅Use a foot stool or a squatty potty when going to the toilet to avoid straining.
This can make a huge difference to opening your bowels post c-section.

✅Stay on top of pain meds
If you let pain build up it is very difficult to get under control but if you take meds regularly you can stay on top of it better.

✅Use a pillow for counter pressure over your incision when coughing and sneezing and going to the toilet.

✅Use a step stool for getting in and out of bed

✅Wear compressions leggings for support.
Leggings such as the leggings can be really supportive.
Use Discount code: ANUWOMENSHEALTH for 10% off

✅Use silicone scar strips to help scar once incision is closed.
These can really help soften the scar and reduce any pulling or tugging on the scar.

Any other tips you found beneficial for your recovery?

06/01/2024

🍾🍾Nollaig Na mBan Shona daoibh

Happy Women’s Christmas, a day when traditionally men did the men did the housework and women together to celebrate 👭.

Nollaig na mBan is a lovely Irish tradition 🇮🇪.

The 6th of January is the day the Mná na hÉireann get to down tools and celebrate together after a busy Christmas. The men take on the duties of cooking, cleaning and child minding, while mothers, daughters, sisters, female relatives and friends celebrate together.

Today we celebrate the amazing community of women in our lives 🥳🥳.

31/12/2023

Athbhliain faoi mhaise daoibh go léir 🍾🍾

"To all the days here and after

May they be filled with fond memories,

happiness, and laughter."

24/12/2023

🎄🎄🎄Wishing you all a Very Merry Christmas from Anú Women's Health🎄🎄🎄.

12/12/2023

🎄🎄The Festive Season can lead to big changes in our day-to-day routine. These changes can bring us joy (or stress!) but can create major difficulties for people dealing with pelvic floor problems, like pain and constipation.

🤔Why Do Holiday Flares Happen?

📌Stress:
The holidays can be extremely stressful! Changes in routine, combined with added pressures, events, and financial difficulties can lead to people feeling incredibly stressed and overwhelmed.
The pelvic floor muscles are known to be threat responders, so this can lead them to overactivate to guard and protect you against all of the stress.

📌Dietary Changes:

Dietary changes can make us more likely to develop constipation. Our habits can also lead to dehydration, as we exchange water for holiday drinks, and scurry around forgetting to get our fluid in.

📌Routine Changes:
it can be really hard to keep our healthy habits up that support pelvic function over the holidays. This leads us to remove some of our self-care from our schedule, and without it, some of our symptoms can start to creep back up.

❓❓❓So, How Can You Make It Through The Holidays Without Worsening Pelvic Health Problems?

Try These 4 Tips!

✅Tip #1: Simplify Your Holidays
Prioritize what is important to you, and remove pressures for what you think "should" be happening. Prioritize joy, family, and quality time, and remove any pressures and obligations that you have placed on yourself.

✅Tip #2: Plan For Healthy Eating & Hydration
Plan your day to make sure you're also eating fresh fruits and veggies, getting adequate fibre, and getting adequate fluid .

✅Tip #3: Create A Daily Stress-Reducing Routine
Take some time to think about what feels relaxing and stress-reducing to you, then try to build that in to your day.

✅Tip #4: Prioritize Your Self-Care
This one is hard as schedules get busy. But, as you plan your days and weeks leading up to the holidays, keep yourself in the equation. Think about the key pieces that are helping you right now, and make sure these stay in your schedule.

07/12/2023

✅Our main breathing muscle is the diaphragm, a dome-shaped muscle under the rib cage.

When we breathe in, the diaphragm flattens out and pushes on our abdominal contents down toward our pelvis.

💪The muscles of the pelvic floor, located between your p***c bone and tailbone, lengthen a little bit. This allows us to manage the increase in pressure in our abdomen that occurs when the diaphragm flattens out.

😤When we breathe out, essentially the opposite happens: the diaphragm relaxes and goes back up toward the heart, the organs move up as well and the pelvic floor muscles contract.

Now if you have to cough or shout - something that requires us to breathe out forcefully, the abdominal muscles are going to contract more forcefully. This increases the pressure in our abdomen a lot.

💪The pelvic floor muscles now have to contract a lot as well, to help prevent things from being pushed down.

For people that have issues with continence, it is often this coordinated movement that is disrupted. Muscles may be too tight (not relaxing enough) or too weak (not contracting enough).

One place to start to help engage the right muscle pattern is to focus on breathing. Try this exercise: lie on your back with a pillow under your head and one under your knees. Breathe in through your nose gently and feel the rise of your belly. Now exhale gently through your nose. Imagine the up and down motion of the diaphragm and the effects on the organs. Do this a few times. Now bring your awareness to your pelvic floor muscles. As you breathe out, see if you can engage them by squeezing them gently. This would be the same as stopping the flow of urine when going to the bathroom (do NOT do that as an exercise). The key is to not only contract when you exhale, but also relax when you inhale. As this gets easier to do, practice in a variety of positions.

And the next time you really, really need to go, but are still a few minutes away from the bathroom, focus on breathing out and contracting your pelvic floor muscles. Trust me, it will help a lot more than holding your breath or breathing in!

05/12/2023

✅We all have great intentions when we are trying to improve some aspect of our health.

❌We set the bar high and berate ourselves when we fail.

No matter what exercise habit you try to create in your life whether it is walking more, getting more sleep or finally doing your pelvic floor exercises consistency is the name of the game.

🤔How can you create more consistency in your exercise habit??

❓Do you need to set reminders??

❓Could you tag it onto something you already do in your day??

❓Do you need to actually schedule it into your diary?

Different things work for people but rather than giving out to yourself, sit down and consider what steps could you take to help improve your consistency??

28/11/2023

✅Kegel exercises on the floor have been synonymous with pelvic floor exercises.

While this is a great place to start this alone is not the only way to support the pelvic floor.

Research has shown that many hips and pelvic exercises also activate the pelvic floor as much as the Kegels.

This is why The Pelvic Floor Revival is more than Kegels. The 6 week online program is jam-packed with exercises that will improve your pelvic health.

Not only will your pelvic floor feel stronger, your pelvis will feel great, and your whole body will feel more energised.

Link in the Bio for more info.

23/11/2023

❗While pelvic floor exercises are important post-birth they are not the only muscles that need your attention.

✅Postnatal women may experience an imbalance in their core/hip muscles, altered breathing patterns, and pelvic floor dysfunction.

🤔Think about how much your body changed over the 9 months of pregnancy. It was not all on the pelvic floor. There are many changes the body has experienced.

Many women think once the baby comes out that everything springs back to where it was pre-pregnancy but this is not always the case.

✅Most women need to target rehabilitation to the whole body, the pelvic floor, the core, the hips and the musculoskeletal system as a whole.

This is best done in conjunction with a professional who understands the changes the body undergoes in pregnancy such as a women's health physiotherapist or pre and post natal trainer.

Check out our online Postnatal Pilates Programme if you want a programme that targets the whole body.

22/11/2023

❗So you have had your baby and now your body feels and works differently to how it used to.

❗Unsure where to start??

❗Afraid to do the wrong exercises for your pelvic floor or diastasis??

You are not alone.

So many women find it difficult to know how to return to exercise safely after pregnancy.

Internet searches can leave you more confused and more afraid to do anything.

✅That is why I have created The Postnatal Pilates Plan. A self-paced online post-pregnancy pilates plan to help you reconnect to your core and pelvic floor and leave you feeling stronger again.

Link in the bio for more info

16/11/2023

❗No, please don't even try.

❌You don’t have to “activate” your pelvic floor while you’re running.

❌Don’t think about it.

❌Don’t try to control it.

❌Do not try to kegel while you’re running.

So what do I do instead? I hear you ask.

When you’re running, your pelvic floor should respond reflexively (naturally).

That means, your pelvic floor should to contract and relax appropriately WITHOUT YOUR CONSCIOUS CONTROL. Runners who don't leak are NOT squeezing their pelvic floor when they run.

Along with the rest of your deep core, your pelvic floor is responding to pressure generated by your breath AND it’s responding to ground impact forces generated by each foot strike.

It’s managing input from above AND from below to keep your pelvic organs supported, your torso stable and you dry.

💪💪That’s a very big job.

You’ve got to trust your pelvic floor to reflexively manage ground impact forces and changes in your intra-abdominal pressure. If your conscious brain tries to get involved, your pelvic floor won’t do its job as effectively.

Pelvic floor exercises and rehab need to be done just not while you run. Create the space to work on your pelvic health and as you begin to trust your body you will see a big difference in the amount of leaking you experience while running.

Check out The Pelvic Floor Revival Programme. An online programme to help you regain control of your pelvic health again.

Link in the bio

13/11/2023

❗❗The magic 6 weeks in NOT enough time to recover after birth.

As a pelvic health physiotherapist who has worked with thousands of women both in person and online, here is a more realistic postnatal recovery time frame.

Weeks 0-2
Prioritise rest and sleep
Reconnect with your breath and pelvic floor

Weeks 2-4
Begin short walks as you are able
Reconnect with deep core and pelvic floor

Weeks 4-6
Still prioritise rest and sleep
Continue to connect to core and pelvic floor
Increase walking gradually
Begin gentle body weight exercise

Weeks 6-12
Begin re building full body strength
Start low impact exercise
Progress core and pelvic floor exercises

Week 12- 26
Potentially add in impact training such as running
Progress full body strength
Don't forget single-leg strength
Continue pelvic floor and core exercises

6 months +
Return to pre pregnancy level of activity as able

If this feels overwhelming book an appointment with a women's health physiotherapist to help guide you along this journey.

There is so much pressure to be "bounce Back" by 6 weeks after birth but this is not realistic.

Be kind to yourself

09/11/2023

The Resistance Band is a fantastic tool to add to your postnatal rehabilitation kit.
Try these 4 exercises:
1. Band pull apart with leg lift
A great one to combine with the breath. Exhale as you squeeze the pelvic floor, pull the band apart and lift a leg.
Repeat 15-20 each side.
2. Straight arm pull back.
So simple but a great way to reconnect with your pelvic floor and tummy muscles again after pregnancy.
Try 12-15 reps. Hold for 5 at the end of each rep
3. Banded clam
The addition of the band makes the simple clam so much more challenging.
Repeat 15-20 each side.
4. Monster walks
Get down into a squat, with the band around the thighs. Walk side to side on your mat. Feel the glutes burn!!!

07/11/2023

🏃‍♀️🏃‍♀️Running is a high impact sport placing a lot of demand on the body. High impact exercise was found to have an increased risk of pelvic floor dysfunction compared to low impact exercise.

❓When is a good time to start?
Postnatal women need adequate time to heal and regain strength, particularly in the abdominal and pelvic floor muscles after pregnancy and delivery.

🏃‍♀️To be run ready, your body needs time to heal and regain its strength after having a baby. For this reason, it is recommended to initially keep to low impact exercises, followed by return to running between 3-6 months post-partum.

✅It is recommended that all women, regardless of how they deliver, seek out a pelvic health assessment with a specialist physiotherapist to evaluate strength, function and co-ordination of the abdominal and pelvic floor muscles which are often impacted by pregnancy and delivery.

There are a number of factors to consider such as pelvic floor and abdominal strength and endurance.

Another factir is whether the body is storng enough? Here are the strength tests for return to running postnatal.

Many women will not be able to perform these test well and a period of strengthening is recommended prior to return to running.

30/10/2023

✅It is important when you open your bowels that you do so in the correct way and in the correct position. This makes it much easier to pass stool and reduces the strain on your pelvic floor muscles.

❗By holding your breath, sucking in your stomach and straining when trying to open your bowels makes the muscles around the back passage tighten. This makes opening your bowels more difficult and can lead to problems such as haemorrhoids (piles), a**l fissures and prolapse.

✅Correct Position

By sitting on the toilet in the correct way it can help the pelvic floor muscles to relax and the re**um opens up to a funnel shape rather than a tight bend.

Do not ‘hover’ over the toilet, always make sure you sit down properly and use a footstool under your feet.

✅The best way to get into this better position is to put a footstool (or a squatty potty)under your feet. This recreates the squatting position we were originally designed to move our bowels in. Make sure your feet are flat on the stool and that your knees are made higher than your hips. Lean forwards slightly.

✅Breathe in, then as you breathe out , try to either make a sound in your throat, for example say the word ‘Idge’ or ‘Ooo’. Or pretend you are blowing a balloon up but don’t actually blow out air.

✅You should be aware of a gentle dropping of your pelvic floor muscles.

✅You should aim to do this every time you start to open your bowels.
These techniques take time to learn but they should help with your bowel problems and pelvic floor health.

26/10/2023

You may have seen our 4 Exercises for Diastasis Recti: Level 1 last month, and this is a follow on video.

So many times women stick with "safe" exercises but then they don't challenge the body.

To improve a diastasis recti we have to load the tissue which responds by getting stronger. These exercises are a progression on the level 1 video so if you have been working on that and finding it easier now it might be time to progress on.

1. Pilates Roll Up

Sit tall on your sitting bone and slowly roll your weight onto your tailbone and onto your sacrum. Imagine pulling your p***c bone up towards your breastbone as you roll back. Hold for a breath and repeat 10-15 times.

2. Side Plank on Knees

This is a great exercise to load the abdominal wall again after pregnancy. build up to 3-5 x 30-60 seconds holds.

3. Bear Plank

On your hands and knees, ensure your shoulders are down and away from your ears. Hover your knees off the ground. Hold 30-60 seconds and repeat 3-5 times.

4. Inclined plank and leg lift

You may have been working on the inclined plank from the last video so now we are progressing to adding in a leg lift.

As with all exercises make sure you are breathing and enjoy!!!

All these exercises and more can be found on The Postnatal Pilates Programme. Link in the bio.

24/10/2023

TOP 5 TIPS FOR A HEALTHY BLADDER

1. Practice good toilet habits

Go to the toilet when your bladder feels full; don't get into the habit of going "just in case".Go to the toilet when you get the urge to open your bowels; don't get into the habit of putting it off as this can lead to constipation.
Take your time. Relax when you are on the toilet.



2. Look after your pelvic floor muscles

Practice pelvic floor exercises regularly. See a continence physiotherapist to check that you are training your pelvic floor muscles the right way.




3. Keep good bowel habits

Avoid constipation and straining when using your bowels. This puts extra load on the pelvic floor muscles and may lead to weakening of the muscles.
Eat a healthy diet rich in dietary fibre.
It is recommended we have at least 30g of fibre a day.

Keep active. Physical activity helps to keep your bowels regular and to maintain a healthy body weight.



4. Drink well every day

Drink 1.5-2 litres (6-8 glasses) of fluid daily unless advised otherwise by your doctor.

The best fluid to drink is water. Limit caffeine, alcohol and sugary drinks as they can cause bladder irritation.
Remember cola, chocolate, sports drinks and some energy drinks are high in caffeine.


5. Sit correctly on the toilet

Sit on the toilet with good posture- elbows on knees, leaning forward with your feet supported on a footstool so that your hips are slightly higher than your hips.
Keep your back straight and let your tummy completely relax and bulge.