Menopause & Urinary Symptoms At A Glance:
- Changes in a womans urinary function often accompany menopause. A primary cause is urogenital atrophy, which is the deterioration of the urinary tract and vagina.
- These urinary changes occur for two reasons: Menopause reduces the amount of the female hormone estrogen, and a lack of estrogen reduces the urinary tracts ability to control urination. Advanced age, which usually coincides with menopause, also has various debilitating effects on the pelvic area organs and tissues.
- Symptoms include the need to urinate more frequently, the inability to control urination , dryness and itching in the vagina, and increased urinary tract infections.
- Treatments vary and include dietary changes, strengthening exercises, topical estrogen for the vagina, and surgery.
A Randomized Comparative Study Of The Effects Of Oral And Topical Estrogen Therapy On The Lower Urinary Tract Of Hysterectomized Postmenopausal Women
- Cheng-Yu LongAffiliationsDepartment of Obstetrics and Gynecology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, TaiwanDepartment of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Cheng-Min LiuAffiliations
- Shih-Cheng HsuAffiliationsDepartment of Obstetrics and Gynecology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, TaiwanDepartment of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Chin-Hu WuAffiliations
- Eing-Mei TsaiCorrespondenceReprint requests: Eing-Mei Tsai, M.D., Kaohsiung Municipal Hsiao Kang Hospital, Department of Obstetrics and Gynecology, 482 Shan-Ming Road, Hsiao-Kang Dist. 812, Kaohsiung, Taiwan .AffiliationsDepartment of Obstetrics and Gynecology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, TaiwanDepartment of Obstetrics and Gynecology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
Vaginal Estrogen And Surgery
It is commonly believed and anecdotal experience would predict that a well-estrogenized vagina heals better and is more resistant to complications such as infections and mesh erosions than more poorly estrogenized tissue. Many expert gynecologic surgeons recommend both pre- and postoperative vaginal estrogen for postmenopausal patients. However, there are few studies available which directly address the issue of vaginal estrogen on perioperative outcome.
It is known that topical estrogen can treat age-related skin changes such as wrinkles and thin skin. Estrogen also increases the rate of cutaneous wound healing in older women and men. Estrogens act on the cutaneous wound healing response by modulating the inflammatory response, cytokine expression and matrix deposition. They also accelerate re-epithelialization, stimulating angiogenesis and wound contraction, and regulate proteolysis. While estrogens impact wound on healing of nonkeratinized vaginal epithelium remains to be described, its potential positive impact, currently adds to the rationale for perioperative use in vaginal surgery. There are no studies that directly compare the ease of the surgical procedure or its outcomes in women pretreated with intravaginal estrogen compared to those without treatment with intravaginal estrogen.
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Lower Urinary Tract Symptoms
Many women find that they have problems with their urinary tract in association with the menopause due to estrogen deficiency.
Some suffer from stress incontinence leaking of urine on coughing, sneezing or jumping, whilst others experience urge incontinence presenting as difficulty holding on once there is recognition of a need to empty the bladder. They may also leak and start to pass urine before they can get to the toilet.
Vaginal Atrophy: Vaginal Dryness Soreness And Painful Sex
Without the production of estrogen by the ovaries, the skin and supporting tissues of the vulva and vagina become thin and less elastic. This is a common consequence of the menopause and the majority of women will experience symptoms of one form or another. Vaginal dryness is commonly the first reported symptom, due to a reduction in urogenital mucus production.
Thinning of the lining of the vagina and vulval skin increases the risk of damage. This is most likely during sex, especially if lubrication is also poor. Even quite gentle friction can cause pain and discomfort. If the vulval lips are thin and dry, rubbing against underwear can cause soreness. Some women find the physical changes to the vulva upsetting due to a reduction in fat content/plumpness. For many women, sex becomes difficult and painful.
Alteration in the normal vaginal discharge is noticed by many women after the menopause and this is rarely discussed. Without estrogen, the pH of the vaginal secretions changes and the normal discharge becomes more alkaline . This change in pH affects the balance of the micro-organisms in the natural secretions, which in turn suppresses the normal levels of goodbacteria . Vaginal discharge changes in nature, becoming watery, discoloured and slightly smelly. This often leads to irritation and can cause burning of the vulva and vagina.
Some women seek advice, but many dont ask for help for this under-recognised problem.
Management of urogenital atrophy
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The Pattern Of Incontinence Is Often Mixed
Symptoms of overactive bladder include frequency and nocturia . Some women also feel they need to pass urine, having only just done so due to over activity of the bladder muscle.
Recurrent urinary tract infections
UTIs can affect women of all ages, but this problem increases with age as a result of estrogen deficiency.
Management of urinary problems
Local estrogen replacement therapy has been shown to alleviate urgency, urge incontinence, frequency, nocturia, dysuria and also to reduce urine infections.
Genuine Stress Incontinence would not appear to be helped by estrogen alone, but it does seem to improve the action of other treatments currently used.
The newer treatments including Ospemifene, DHEA and laser therapy may all have a beneficial effect on bladder problems.
Pelvic floor exercises
These can strengthen the pelvic floor reducing the risk of uterovaginal prolapse. Many women have learnt these techniques from childbirth, but it is well worth revisiting them.
Pelvic-floor physiotherapists are specialists in this field and are able to fully assess and monitor a womans pelvic floor function and teach appropriate techniques to strengthen it and retrain the bladder. They often use devices to help women perform appropriate exercises, such as weighted vaginal cones, or vaginal trainers. Your practice nurse or GP should be able to refer you to a specialist pelvic floor physiotherapist.
Get Effective Treatment With A Team Approach
Women need to know that there are many options available to reduce and sometimes eliminate pelvic organ prolapse. I encourage women not to accept their symptoms as milestones of motherhood or aging. With active research into advanced techniques and new developments each year, women should feel empowered to ask their doctors for the latest treatments for incontinence and pelvic discomfort.
Find out more about pelvic organ prolapse treatment today. Call or request an appointment online.
The Vagina As Drug Delivery System
In 1918 Macht demonstrated that the vagina was able to absorb drugs including morphine and atropine. While drugs administered vaginally are often used to treat local conditions, these drugs may also act systemically. Some oral agents are commonly used vaginally for non-FDA indications such as misoprostol for labor induction. Oxybutynin was initially marketed as an oral formulation and now is available in a vaginal ring for treatment of overactive bladder. The use of the vagina as a drug delivery system will most likely continue to increase because of the many qualities that make it suitable for absorption of drugs. Oral administration of drugs may be complicated by vomiting, variations in GI absorption, and drug interactions. Similarly, transdermal application is susceptible to variable outcomes based on levels of adiposity. One of the major advantages of vaginally administered drugs is avoidance of hepatic first pass effect, which affects the absorption, distribution and excretion of orally administered drugs. This results in use of lower doses to achieve equivalent therapeutic effect. Also, patients may benefit from less frequent dosing which decreases fluctuations in drug levels and can result in fewer side effects.
Absorbent Pads And Garments
There are various products that you can try if medical treatments cant eliminate your symptoms. For example, you can wear absorbent pads. Remove the paper lining covering the adhesive and place it on the bottom of your underwear.
Not only will they keep you dry, but theyll also help reduce the odor of urine.
Men with incontinence can also use drip collectors. Theyre small absorbent pouches, which are attached to the penis and held in place by your underwear.
What Is The Role Of Estrogen Therapy In Urinary Incontinence Treatment
Estrogen therapy may have several positive effects in women with stress incontinence who are estrogen deficient. Estrogen may increase the density of alpha-receptors in the urethra. In addition, it increases the vascularity of the urethral mucosa and may augment the coaptive abilities of the urethral mucosa. In theory, those effects should translate into improved continence however, several studies stand in opposition of those assumptions.
A number of small studies show oral estrogen therapy to be of no clinical benefit to women with stress incontinence or detrusor overactivity. In a subgroup analysis of postmenopausal women enrolled in the Heart and Estrogen/Progestin Replacement Study , worsening of incontinence occurred in 39% of patients in the hormone treatment group, compared with 27% of patients in the placebo group.
In the Women’s Health Initiative Study, women with baseline incontinence being treated with combined or unopposed estrogen oral therapy also showed exacerbation of symptoms significantly more often than women in the placebo group. In addition, women in the hormone-exposed groups with no baseline incontinence developed symptoms more often than those in the placebo group.
Pharmacologic therapy using estrogen derivatives results in few cures but may cause subjective improvement in 29-66% of women. It may be useful in postmenopausal women with atrophic vaginitis or intrinsic sphincter deficiency.
Does Estrogen Replacement Therapy Help With Incontinence
As women age, they experience a gradual loss of estrogen. The rate of loss increases as menopause approaches. Low estrogen levels are associated with a number of symptoms, one of which is urinary incontinence. This happens because estrogen helps maintain connective tissue and muscle tone in areas that have many estrogen receptors, such as the vagina, urethra, and bladder.
Given that estrogen plays such a significant role in the function of these tissues, it makes sense that replacing the estrogen might be a good idea. For years, millions of women took synthetic estrogen to manage the symptoms of menopause, but in 2002 the Womens Health Initiative study data showed that estrogen replacement might be causing more harm than good. In that study, oral estrogen replacement, in combination with medroxyprogesterone , was associated with increased risk of cancer, stroke, and blood clots.
The majority of studies of oral estrogen for treatment of incontinence have shown that it actually makes symptoms worse in women who already have incontinence and can trigger incontinence in women who dont already have it. Therefore, oral estrogen is not recommended as an option for treatment of incontinence.
Additionally, you can find varying levels of products for incontinence at TotalHomeCareSupplies.com.
Data Collection And Analysis
Eligible studies were selected from the identified references by applying the inclusion criteria, first on title and abstract, and in a second step on full text.
If studies were sufficiently similar with regard to clinical aspects and study design, a pooled effect was calculated using Review Manager software. In case of substantial heterogeneity a random effects model was used.
Studies that did not report their results in enough detail to allow data extraction were not included in the appendices with the analyses. The results of these studies are described narratively in the Results section.
The effect measures were risk ratio for dichotomous data and mean difference for continuous data, with 95% confidence intervals . Data analysis was performed using Review Manager software following the guidance the Cochrane Reviewers Handbook
Epithelial Estrogen Receptor Analyses
VK2 E6/E7 cells seeded at a density of 1 × 105 cells/well were pre-treated with either 1µM ICI 182,780 known as fulvestrant or 0.1% DMSO vehicle and 4nM -cyclodextrin encapsulated 17-estradiol or cyclodextrin vehicle for up to 7 days. The culture medium, ICI 182,780, encapsulated 17-estradiol or cyclodextrin were replenished every 48hours and 24hours before a flagellin 50ng/ml or PBS challenge.
For G-protein coupled estrogen receptor stimulation VK2 E6/E7 cells seeded at a density of 1 × 105 cells/well were pre-treated with either 100nM GI or 0.01% DMSO vehicle and 4nM -cyclodextrin encapsulated17-estradiol or cyclodextrin vehicle 24hours before a flagellin 50ng/ml or PBS challenge. The culture medium, 17-estradiol or cyclodextrin were replenished every 48hours.
Urinary Incontinence And Menopause Unlinked
Menopause may have little, if any, effect on the risk for urinary incontinence , according to an epidemiologic review October 29 and in the January 2013 issue of Maturitas.
Guillaume Legendre, MSc, from the Gender, Sexual and Reproductive Health Team of the CESP Centre for Research in Epidemiology and Population Health, Paris-Sud University in Villejuif, France, and colleagues assessed the findings of 488 articles in the current literature, retaining 29 articles total, including 3 meta-analyses, 4 literature reviews, 5 randomized controlled trials, and 12 cohort studies.
The researchers’ findings suggest that any relationship between UI and menopause is tenuous at best and that hormone replacement therapy may paradoxically make some forms of UI better or worse, depending on mode of administration: systemic therapy increases symptoms, particularly that of stress urinary incontinence , whereas vaginal use of topical estrogen eases symptoms of overactive bladder.
Links to Many Factors
“Female urinary incontinence is a complex and dynamic phenomenon, related with age and…many other factors that can change with time. In order to gain greater insight, longitudinal studies are necessary, with several years or even decades of follow-up in order to clarify its evolution and risk factors,” the authors conclude.
With respect to HRT, Legendre’s group found that its effects varied based on UI type and mode of HRT administration.
Bladder Storage Symptoms And Urinary Incontinence
The decrease in ovarian estrogen production at the time of menopause causes atrophic changes in the vulvar, vaginal, urethral and bladder tissue. While vasomotor symptoms may resolve in a few months or years, vaginal and other urogenital symptoms may actually increase as the patient ages. The effects of estrogen are manifest by the presence of Estrogen Receptors . Estrogen receptors have been shown in biopsy specimens from the bladder trigone, proximal urethra, distal urethra, vagina and vesico-vaginal connective tissue contiguous with the bladder neck., , While ERs were present in urethral squamous epithelium, they were not present in urothelial tissue of the lower urinary tract. Progesterone receptors are more variable and found mostly in subepithelial tissues.
Decreased estrogen levels after menopause causes atrophic urogenital symptoms with several recent studies confirming resultant dysuria and other lower urinary tract symptoms such as urgency and frequency. Iosif studied a cohort of Swedish women and found a 50% incidence of urogenital symptoms including dryness, itching, burning, urgency and frequency. Barlow reported that 23-40% of menopausal women report at least one urogenital symptom. In a 1954 paper, Youngblood reported that symptoms of urgency and irritation were due to atrophic urethritis which is defined at symptoms of UTI without a positive culture.
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We Hope To Change This Story
An ongoing clinical trial is examining the effectiveness of vaginal estrogen a supplemental, nonsurgical therapy to reduce symptom recurrence and spare more women the risks and financial implications of revisional surgeries.
For an appointment, please call Dr. Rahn at to discuss treatments.
Vaginal estrogen, when used prior to surgery, improved the resilience of the connective tissue in the pelvic floor.
David Rahn, M.D.
Products And Medical Devices
You may be able to use the following products to help stop or catch leaks:
Adult undergarments are similar in bulk to normal underwear but absorb leaks. You can wear them under everyday clothing. Men may need to use a drip collector, which is absorbent padding held in place by close-fitting underwear.
A catheter is a soft tube you insert into your urethra several times a day to drain your bladder.
Inserts for women can help with different incontinence-related issues:
- A pessary is a stiff vaginal ring you insert and wear all day. If you have a prolapsed uterus or bladder, the ring helps hold your bladder in place to prevent urine leakage.
- A urethral insert is a disposable device similar to a tampon that you insert into the urethra to stop leaks. You put it in before doing any physical activity that usually causes incontinence and remove it before urinating.
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Vaginal Estrogen And The Endometrium
Intravaginal application of estrogen plays a unique role in hormone replacement therapy because of evidence that there is preferential delivery of hormones supplied in the vagina to the endometrium. This has been termed the first uterine pass effect. This phenomenon is theorized to be the result of countercurrent exchanges with vein to artery diffusion. While this phenomenon is known to occur in the upper third of the vagina it was unclear if this occurs throughout the vagina. A recent study examined this phenomenon. Vagifem® was applied in postmenopausal women either in the lower or upper third of the vagina. Estradiol levels along with Doppler velocity measurements were made both at baseline and after 2 hours. Application to the upper third of the vagina resulted in statistically significant higher serum estradiol levels but only a small absolute difference compared to the lower third of the vagina. Also, with application of Vagifem® to the upper third of the vagina, there was a decrease in pulsatility index and resistance index which was not seen with lower third application. Thus, the first pass uterine effect appears to be exclusive to the upper third of the vagina. With application to the lower third of the vagina there was preferential delivery to the periurethral area.