Many women reaching perimenopause start to notice they leak when they exercise or laugh, or that they need to go to the bathroom more frequently. This is an irritating situation, and there may be a few causes for this;
- The muscles of the pelvic floor and the small sphincter muscles of the urethra are like any other muscle, in that they lose bulk, contraction strength and endurance with increasing age. This means they generate less pressure to close off the urethra, and leaking can occur. Also, the reduced bulk of the pelvic floor muscle means that the bladder may drop lower in the pelvis making it even harder for the muscles to squeeze the urethra closed.
- Menopause also signals a change in the hormonal profile of the vaginal and urethral mucosa. Estrogen effects this area by increasing vascularity and blood flow, which plumps up the tissues. Estrogen may also impact the way our nerves tell a muscle to contract and assists with maintaining the length of a muscle contraction. As estrogen declines in menopause, the tissues very commonly become dry, sensitive and can even shrink (called vulvovaginal atrophy or VVA). Before the urethra was quite easy to compress, as the moisture made it like a wet plastic bag which likes to cling together, but with menopause, it requires even more muscular effort to close off. This combined with the weakening the muscular contraction can create a perfect storm for leaking!
- It’s also quite common to have changes in bowel function with menopause and ageing, including constipation. There is a really strong link between constipation and increased urgency and frequency as well as leaking because the increased pressure impacts the nerves which innervate the urethral and pelvic floor muscles. Weight increase is another common issue around menopause, and there is strong research showing with increasing weight, there is increasing incontinence. The catch-22 is that research also shows us that incontinence with exercise is a barrier to participation, then it becomes even harder to maintain weight, and the leaking gets worse!
So with these issues, what can actually be done to help?
Treatment needs to be multi-faceted and customised to the individual. The first step is to assemble a good team to help manage the issues. GP, gynaecologist, and pelvic floor physiotherapists are good places to start. Your physiotherapist may assess your fluid intake and bladder volumes with a bladder diary, which can further help to diagnose the type of incontinence you are experiencing (urge or stress incontinence). Once you know what you’re dealing with you can explore different treatments.
There is excellent research to support muscular strengthening to reduce stress urinary incontinence. We can combat the age-related changes of any muscle via exercise, so if you are assessed by your pelvic floor physio and these muscles are weak, then you have a great chance of improvement. But not everyone has weak muscles, in fact, some people are not good at relaxing them. It’s really important to get checked by a professional as kegels are not always the answer!
Your GP or gynaecologist may prescribe a topical estrogen cream (Ovestin and Vagifem are common brands). There is good evidence to show that topical estrogen can increase the vascularity of the area and re-plump the urethral tissues. It’s also thought to improve the nerve messages to the pelvic and urethral muscles and improve contraction duration.
If your Pelvic health physiotherapist or Gynecologist think increased mobility of the urethra or prolapse may be part of the picture, a support pessary can be really helpful. These can be fit by your specially trained pelvic health physio, and self-managed.
There are several other treatments available – a popular option being vaginal laser for “vaginal rejuvenation” which is aimed at re-vascularising the vulvar tissues. Women need to be aware that the FDA released a statement in June 2018 advising women that the effectiveness of such treatments have not been established and as such these treatments have not been FDA approved.
Managing your bowels well is one of the best things you can do for your pelvic health. An excellent diet full of live fibre chewed thoroughly is a great start. Exercise is crucial here as “motion helps the motions!”. It’s my opinion that everyone should use toilet stools for bowel motion – seriously.
So bottom line – if you are noticing changes as you hit menopause, assemble a great pelvic health team who can help you reach your goals!