Many of us (men and women) have had moments where we sneezed and lost control of our bladder, or we had a coughing attack and sprang a little “leak.” But for women in menopause, urinary leakage can occur more frequently and cause embarrassment and concern. Urinary incontinence is actually common during this time in a woman’s lifespan and can be the result of one or more causes. Fortunately, there are many ways to address this problem.
What is urinary incontinence?Simply put, urinary incontinence is the involuntary leakage of urine.1 Up to one-third of men and women in the US have urinary incontinence,1 but it is older women—those going through perimenopause and menopause—who most often develop stress urinary incontinence (SUI).1 Urge incontinence (UI) is also common in postmenopausal women; also known as overactive bladder (OAB), the condition results in a fast, urgent need to urinate, accompanied by urine leakage.2
Bend. Lift. Leak.As time marches on, children are born, and estrogen levels drop, the pelvic floor muscles that support the bladder and other organs can naturally weaken and become stretched. Less support means less ability to hold urine, and when the urethra (the duct where urine comes out of the body) is challenged by a good sneeze or lifting a box, it can leak out a few drops, or up to a tablespoon or more.1 This is SUI, and a decline in estrogen levels plays an important role in its development during menopause, at which time the tissues of the urogenital tract can weaken and become thin.3,4 Additionally, giving birth multiple times, or traumatic vaginal birthing, can contribute to SUI in menopause.4
Gotta go—now!Urge incontinence (UI) is the sudden urge to urinate, often accompanied by urine leakage. In addition to the weakening of pelvic tissues during and after menopause, UI may be caused by a lack of coordination between the brain and bladder, with the signal to urinate being sent by the brain at the wrong time.5Other symptoms of UI include urinating more than eight times per day and more than once at night (nocturia).5
What can be done about urinary incontinence?There are several ways to help make it easier to deal with urinary incontinence. You may start by refraining from alcohol and caffeine; stopping drinking liquids close to bedtime; wearing a disposable pad designed to absorb urine; and maintaining a healthy weight. There are also more comprehensive methods available to address urinary incontinence.
Pelvic floor strengthening exercise--The beloved Kegel exercise is a well-known way to help strengthen pelvic floor muscles and possibly eliminate bladder leakage.6 By contracting and relaxing these muscles repeatedly, they can be strengthened and provide better bladder support. Where are your pelvic floor muscles? If you can stop urinating midstream, you’ve found them.6 Ask your healthcare practitioner for information on how to perform the Kegel exercise.
Pessary--This small device is inserted into the vagina to help support the pelvic organs and is also used to treat urinary incontinence. Fitted by your healthcare practitioner, a pessary is removable, minimally invasive, and discreet. There are also over-the-counter, disposable bladder supports available that are self-fitting.7,8
Biofeedback--Small sensors are discreetly placed on the body and used to measure what the pelvic floor muscles are doing, as well as provide feedback to help teach you how to control the pelvic floor muscles.9
Medication--Drugs that are designed specifically for urinary incontinence can be used alone or with a method such as biofeedback; they work primarily by relaxing the bladder muscle and increasing the amount of urine the bladder can hold.10
Surgery--While surgery is more invasive than other ways that address urinary incontinence, it can also successfully resolve it. Procedures such as sling surgery and bladder neck suspension can help keep the urethra from moving down and opening accidentally.11
No matter which method you wish to try, always ask your healthcare practitioner about which is right for you. He or she knows your personal health history best and can help you find relief from menopausal urinary incontinence.
This information is for educational purposes only. This content is not intended as a substitute for professional medical advice, diagnosis, or treatment. Individuals should always consult with their healthcare professional for advice on medical issues.
Interview with Lyra Heller, MA
Our bodies change as we age—as hard as we might fight it. For women who want to maintain a sexually active life with a partner, that may mean accommodating some physical changes. We talked to Lyra Heller, MA to learn her advice on what we can do in order to keep that libido alive.
How does menopause affect sex?
This is a complex question because women’s sexuality is complex. Part of your experience around sexuality and your sexual response is governed by changing hormones. The major impact centers on what menopause means to you, what it symbolizes, your relationship with your partner, and your general health and sense of wellbeing.
How do changing hormones affect sex?
Menopause is a process. It’s a major life transition marked by declines in sex hormones that signal the end of your reproductive years. Perimenopause is the first phase. It can begin sometime in your 40s and may extend into your mid-50s. The symptoms are related to fluctuating hormone levels that cause changes in menstrual cycle quality and frequency, hot flashes, spontaneous sweats leading to poor sleep quality, anxiety, and moodiness. You may notice some weight gain.
Desire to engage in sex can be the last thing on your mind because you are tired, uncomfortable, possibly self-conscious. As estrogen levels continue to decline, vaginal dryness, which loosely translates as you don’t lubricate as well when you’re sexually aroused, may become an issue. This can result in painful intercourse, and it can produce a sense of negativity as you approach sex, because it hurts. Part of the menopausal experience is the vaginal lining tends to thin, and sometimes the walls of your vagina can narrow, so intercourse in general can be hurtful.
How do your feelings and thoughts about menopausal changes affect sex?
Christiane Northrup, author of Women’s Bodies, Women’s Wisdom: Creating Physical and Emotional Health and Healing says, “Thoughts are an important part of your inner wisdom, and they are very powerful. A thought held long enough and repeated often enough becomes a belief. A belief then becomes your biology. ”1
Menopause is a time of physical transformation that encompasses the aging process. Desiring an active sex life at times requires engaging in difficult and rewarding conversations with yourself and your partner because your body may not perform as before. Sounds simple enough, but it can be challenging to communicate “what turns you on.” Yet this may become a core issue. Other considerations that dampen sexual desire are:
Aging seems to come with increased aches and pains, whether from arthritis or just general physical deterioration. How can pain affect a healthy sex life?
Pain hurts a healthy sex life! You don’t want to have sex when you hurt. So what happens is, you decide to control the pain. And there are pain medications that will actually reduce your desire to have sex. In fact, a lot of medications can cause sexual problems. Plus, drug combinations and mixtures of prescription with over-the-counter (OTC) medications are all capable of inducing disinterest in sex.
This is where lifestyle becomes really important. If you’re suffering from a chronic health condition, the trajectory of seeking relief should start with a self-focused approach in partnership with your healthcare practitioner. Some of the major issues requiring medications that might affect your sex life can be elevated blood pressure, depression, anxiety, gut problems, and others2—these are all things that can in some instances also be helped by diet and lifestyle and becoming more physically active. With minor health concerns, a healthcare practitioner can provide guidance on what lifestyle modifications may help. Think in terms of being more proactive in how you approach your food choices, how you want to deal with the excess burden of weight, how you want to deal with blood pressure, adrenal function, and elevated blood fats—these are all capable of being modified by a healthy lifestyle.
If you have had a heart attack or have coronary artery disease, do you need to be concerned with continuing normal sexual activities?
Typically there is no concern as long as there is doctor oversight. If you experience shortness of breath, can’t walk very far, have poorly controlled blood pressure, those kinds of things are going to affect sexual vitality. That said, cardiovascular disease is the leading cause of death for women.3 It is important to appreciate your heart disease risk may go unrecognized even though knowledge about gender differences grows.4
New research suggests that women experiencing hot flashes before age 42 may have an elevated risk of cardiovascular disease when compared to women with late onset vasomotor symptoms (older than 42).5So heart disease is not restricted to women over 65. A baby aspirin a day may not be enough protection.6
Take your heart health seriously. If you are under the age of 65, and especially if you have a family history of heart disease, pay close attention to heart disease risk factors. The risk factors for heart disease are the same as for premature estrogen decline associated with early perimenopause: smoking, physical inactivity, overweight, standard American diet.7
Be proactive. Talk with your doctor.
Are there any options out there that can help with libido?Experiencing perimenopause and libido is different from experiencing postmenopause and libido. Perimenopause is a rollercoaster ride of fluctuating hormones. Hot flashes and night sweats reduce your sleep. With the exception of some women whose sex drive may increase during perimenopause, you’re tired or irritable or anxious. If you’re depressed, it may worsen. You may feel old and ugly. As the extreme symptoms subside, if your libido is still hovering around zero, see a doctor to discuss possible interventions.
There are several noteworthy methods: vaginal lubricants, moisturizers, and topical hormones.
Water-based vaginal lubricants have a short-term effect on dryness. Vaginal moisturizers differ in that they have a longer-term effect and are prescribed on a regular basis—daily or every 2–3 days, depending on the extent of the dryness. Hyaluronic acid vaginal gel may improve symptoms of vaginal dryness, comparable with the effect of topical estrogen therapy. Both are recommended to reduce friction contributing to painful intercourse.
Low-dose vaginal topical estriol, a weak estrogen, is an effective way to kindle sexual desire in some women and reduce vaginal dryness. The effect is different from oral hormone replacement therapy (HRT). Topical estriol seems to exert local as opposed to systemic effects. There are other topical hormones available that your doctor can prescribe, as well.
If want to be sexually active throughout life, you can. It is a choice—a healthy, rewarding choice. Libido can be nourished. Discovering your capacity for creativity, curiosity, and experimentation is critical to being “turned on.” Grappling with the physical changes of menopause stimulates the need to explore your beliefs and feelings about what is means to be sexually intimate as we age. This can involve venturing into uncharted waters on the adventure of a lifetime.
This content is not intended as a substitute for professional medical advice, diagnosis, or treatment. Individuals should always consult with their healthcare professional for advice on medical issues.
By Nilima Desai, RD
If you have ever experienced hot flashes, night sweats, etc., due to menopause, you are not alone. About 80% of menopausal women suffer from hot flashes, night sweats, sleep disturbances, depression, anxiety, and vaginal dryness,¹ which can significantly affect their quality of life. Menopause is characterised by a decrease in estrogen levels, which triggers these uncomfortable symptoms. Most women report hot flashes to be the most bothersome symptom and the reason for starting hormone therapy.²
Symptom Relief OptionsIn addition to lifestyle recommendations, such as following a plant-based diet, increasing physical activity, and minimising smoking and alcohol intake, the addition of hormone replacement therapy (HRT) has been most effective in reducing vasomotor symptoms (hot flashes, night sweats) commonly associated with decreased estrogen levels.²,³*
However, current recommendations from the American Congress of Obstetricians and Gynecologists suggest limiting HRT to the lowest effective dose for the shortest amount of time possible.⁴ As a result, 40-50% of women choose to use practical alternative options, such as plant-derived solutions to address menopause-related symptoms.³ Various plant-derived solutions including phytoestrogens such as isoflavones, lignans, and other Chinese and herbal remedies such as ginseng, black cohosh, etc., have been studied for the relief of menopausal symptoms.*
Plant-Derived SolutionsPhytoestrogens are a group of nonsteroidal plant-derived compounds with estrogen-like properties. The chemical structure contains a phenolic ring that enables them to bind to estrogen receptors in the body.⁵ They bind to both types of estrogen receptors, Erα and Erβ.⁵ However, research suggests that majority of the phytoestrogens have a higher affinity to bind to Erβ as compared to steroidal estrogens.⁵ Therefore, they may exert their actions through different pathways and may potentially induce different beneficial responses.*
There are four classes of phytoestrogens: isoflavones, lignans, coumestans, and stilbenes.⁶
Results from 21 randomized controlled trials (RCTs) examining the association between different phytoestrogens and menopausal symptoms (frequency and duration of hot flashes, vaginal dryness, etc.) included in a meta-analysis concluded that there was an association of overall phytoestrogen use with a decrease in the number of daily hot flashes and in vaginal dryness scores.³ However, the use of phytoestrogens was not associated with significant changes in 24-hour night sweat episodes.³*
ERr 731® is a standardized extract of Siberian rhubarb root, a plant-derived, nonhormonal therapy designed to alleviate menopausal symptoms, including hot flashes.*
In a confirmatory RCT involving 119 perimenopausal women, compared with perimenopausal women receiving placebo, those receiving ERr 731® experienced a median 83% decrease in daily hot flashes over the course of 12 weeks.⁷ Compared to placebo, perimenopausal women who received ERr 731® (the extract found in Estrovera) experienced a decrease in symptoms (as indicated by an average [mean] reduction) of up to 83% in individual Menopause Rating Scale scores.⁸ Clinical benefits of ERr 731® appear to be related to selective binding of Erβ and lack of affinity for Erα.9,10*
Black cohosh is an herb that has a long history of use for the relief of menopausal symptoms, including hot flashes and night sweats. Results from four RCTs examining the association between black cohosh with menopausal symptoms included in a meta-analysis concluded that black cohosh was not associated with changes in the number of hot flashes and night sweats within a 24-hour period.³ Therefore, although black cohosh is a popular herbal remedy to address menopausal symptoms, research has shown no significant association between black cohosh supplementation and relief in menopausal symptoms.³*
Other herbs: There aren’t many studies conducted on the associations of Chinese and non-Chinese medicinal herbs with menopausal symptoms. The few RCTs conducted on the various herbs were not consistent and in general didn’t show any association with symptom relief.³*
Although many RCTs have been conducted on phytoestrogens and herbal remedies in relation to menopausal symptom relief, further studies are needed to determine potential long-term adverse health effects.*
Next StepsUse of HRT needs to be evaluated carefully, and the clinician should assess the risks and benefits associated with prescribing HRT for each individual woman based on her symptoms and personal and family medical history. For women who choose to avoid or have contraindications to HRT, plant-derived therapies in conjunction with a patient-centered approach may potentially provide an alternative in relieving certain symptoms associated with menopause. To determine the best options, patients should always consult with their healthcare provider.
*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.References: