Leaks with Menopause and Aging
Menopause and aging are normal parts of the female lifecycle, and deserve normalized, proactive care. If you're in your 40s or beyond, this is a must read. Here’s what to know.
It’s common to develop bladder conditions with menopause and age. ‘Menopause’ and ‘Age’ are different causes of bladder conditions, but often get confused for each other because they happen to occur around the same time. Distinguishing the cause of a symptom accurately is important for determining appropriate treatment. We’ll be discussing bladder symptoms in the context of both causes.
"Menopause” is defined as the last period, typically occurring between age 50 to 52. It’s a singular event, and is determined once you’ve gone a full year without a period. Periods often get sporadic in the time leading up to menopause, so knowing the last one has occurred is really hard to pin down. Most women won’t know they’ve hit menopause until they’re well past it.
The time leading up to menopause (the last period) is the “menopause transition”. This can start occurring up to a decade before menopause, and varies wildly between people, as do the symptoms. The hallmark sign of menopause transition is irregular periods.
The largest determinants of menopause age are genetics and smoking. A mother’s or sister’s experience can provide clues as to your own menopause; followed by smoking or the exposure to other endocrine-disrupting chemicals, such as pesticides, plastics, pollution, cannabis, and more, which can alter the normal menopause age.
'Common’ does not mean ‘normal’. For something to be ‘common’ does not mean that it is unproblematic or safe, or needs to be tolerated. Let’s keep this in mind as we dive into bladder health during menopause and aging.
Bladder Leaks (Incontinence) with Age:
The risk of Urinary Incontinence (UI) increases with age. Roughly 25% of young women, 50% of middle aged women, and 75% of older women have UI, with less than half of these women seeking care. UI is also underreported, so the true prevalence is probably even higher.
Stress Urinary Incontinence (SUI) is the involuntary loss of urine during activities that put increased stress on the bladder. Examples include: coughing, sneezing, running, jumping, lifting something heavy, bending over, tripping, and laughing. These activities increase pressure in the abdomen, which transmits force to the bladder and urethra, which increases the demand for the pelvic floor muscles to squeeze (or contract) and keep urine in. If the muscles and other supportive elements can withstand the increased pressure, then there is no leaking. But if the pressures overwhelm the support structures, then leaking occurs. The specific activities that cause leaking, and to what degree, vary widely between individuals.
Likelihood for SUI depends on genetics, estrogen levels, and age, among other things. The risk of SUI increases with age, obesity, smoking, decreased estrogen, use of some menopausal hormone therapy, childbirth injuries, and repetitive strain (like chronic constipation).
Solutions for SUI often start with behavioral modifications and pelvic floor exercises. Behavioral modifications typically focus on good fluid intake and a voiding schedule. These can be especially useful for those who have developed unhelpful habits like avoiding fluids or going ‘just in case’, or an overactive bladder that is more responsive to external cues like running water when the bladder isn’t really full.
Pelvic floor exercise typically means “kegels”, the term for contracting the pelvic floor muscles, which keep the urethra closed for continence. The processes of aging and menopause result in changes to vaginal tissue, muscle mass, and connective tissue quality that can result in weakness of the pelvic floor. Pelvic floor exercises are shown to be highly effective at improving continence. Further solutions for SUI include supportive devices worn in the vaginal canal called pessaries, vaginal hormone treatment, surgery, removal of dietary triggers, modifying medications that affect the bladder, weight management, treatment of constipation, and smoking cessation.
Here are some other bladder conditions that become more common with age and menopause, and can affect continence.
Recurrent Urinary Tract Infections (UTIs):
Main symptoms of UTIs include: increased frequency of voiding, increased urgency to go, painful voiding, and blood in the urine. UTIs, especially increased urgency, can also exacerbate incontinence. The risk and recurrence of UTIs increases with age, especially post-menopause. The risk of UTIs after menopause is largely related to low estrogen, which results in changes to the pelvic floor tissues. For example, the protective bacteria in the vagina is replaced with bacteria more likely to cause infection for the bladder. Also, negative impacts to the immune system from decreased estrogen and from aging processes can make a person more prone to infection. It is important to take preventive measures for UTIs not only to avoid troublesome symptoms, but to avoid recurrent use of antibiotics, which causes other issues. The first step if suspecting a UTI is to visit a doctor’s office to get a urine culture to confirm a UTI so that the right antibiotic can be prescribed - this should not be up to guesswork.
Effective options for prevention of UTIs include: vaginal estrogen and prophylactic antibiotics or supplements. Options that lack evidence to support their use include: cranberry, vitamin C, probiotics, wiping front to back, and peeing after sex.
Pelvic Organ Prolapse (POP):
POP is the lowered position of the bladder, vagina, uterus, and/or rectum (one or a combination). Some lowering is normal with age, and minor POP is extremely common. It’s not considered a medical issue unless it causes issues, like difficulty pooping or peeing. It’s really important to understand that some degree of POP is normal, and that medical intervention isn’t necessary unless a person is bothered or hindered by symptoms.
POP is not specific to menopause; rather it is related to factors that weaken the tissues such as age, childbirth, smoking, and chronic constipation; and there is also some genetic susceptibility. It is important to meet with skilled pelvic health professionals to be fully informed of your options and the benefits and risks of each. Look for a pelvic health physical therapist for first line rehabilitative treatment and exercise, and a physician who is board certified in urogynecology for pessary fitting or surgical options.
First line treatment is typically pelvic floor exercise and/or pessary use. Both treatments are highly effective. Pelvic floor exercises strengthen the support structures in the effort to reduce symptoms and improve bladder and bowel function. Pessaries are worn in the vagina, similar to a tampon, and support the positions of the organs in order to reduce symptoms and improve function. Pessaries are successful for about two-thirds of women who are correctly fitted by a skilled provider. Pessaries that do not require fittings are also available commercially without a prescription or doctor’s visit, and are inserted and removed independently very similar to that of a tampon or menstrual cup.
It’s possible for POP to mask urinary incontinence. The POP can “kink” the urethra, helping to hold urine in. When POP is treated, the kink is removed and the person now leaks. Pelvic floor exercises that treat POP symptoms can also address the causes of UI. So both symptoms may be treated concurrently.
In summary, aging and menopause contribute to tissue changes, muscle weakness, risk of infection, and more, that can lead to urinary incontinence. Symptoms from these two separate events often start to appear around the same time, but deserve to be recognized for their separate contributions to symptoms. Effective and specific treatment for UI during this time is available for you!
** Note: this content serves as educational only. It does not constitute medical evaluation, treatment, or advice. Please consult with your medical provider(s) as needed, before partaking in changes to your medical, fitness, or health care practices.