Urogynecology and menopausal impact
Like Urogynecology, menopausal impact suffers from little Recognition. We deal with all the things that no one wants to talk about, all the things that can go wrong in the pelvis. Lots of people have never heard of Urogynecology. I once switched dentists because he told me Urogynecology wasn’t a “real” specialty…that’s a story for another day.
To be fair, it is a new specialty; the first board certification was only in 2013. This was less than ten years ago! Many of the health issues that we manage worsen through menopause. The details of menopause and the impact on the female body aren’t talked about much. There’s nothing talked about in sex education classes. There is more content in magazines today than ever before, but it still isn’t enough. This is true in the medical literature too. I recently read an 8-page article about knowledge gaps in the care of menopausal women. The article didn’t mention incontinence once and had one sentence about urinary tract infections.
So, let‘s talk about how the pelvic floor changes through menopause.
National statistics tell us that most women live 1/3 of their life after menopause. Menopause is when the ovaries stop producing estrogen. Hormones levels fall, and menstruation stops. Estrogen is a powerful hormone and impacts how the body works in many different ways. It impacts many of our other systems, not just the reproductive tract. Your anal sphincter and bowel, pelvic floor muscles, connective tissue (like the uterosacral ligaments), and lower urinary tract are all covered in estrogen receptors. There is a whole body of research focused on how a decrease in estrogen changes these systems. And while it is hard to determine what percent of the change is due to estrogen levels and what is secondary to generalized aging, it is clear that estrogen influences how much of the pelvic works.
Vaginal and bladder changes
As estrogen levels decrease, the vaginal tissue becomes thinner and more delicate. There is less elasticity, less lubrication, and more dryness. These changes in tissue quality can lead to symptoms like vaginal burning, vaginal dryness, and pain with intercourse. The tissue in the urethra and bladder also changes. Many women will also experience needing to urinate frequently, more bladder leaking, and even pain with peeing. These bladder and vaginal symptoms are so common that the syndrome has a name. Medically this is now known as “Genitourinary Syndrome of Menopause” (catchy, I know). An older term for these changes is vaginal atrophy.
More than 50% of menopausal women will have at least one of these symptoms.
This is a truly annoying and uncomfortable set of symptoms. And they can be confusing. Many women mistake these tissue changes for a urinary tract infection. And pain with intercourse can lead to avoiding intercourse. Avoidance is a normal defense mechanism when something hurts. And all of this diminishes quality of life. I’ve heard this called the “Golden Girls Dilemma.” Changes in the vaginal tissue are a normal part of the aging process, but we don’t really like to talk about the vagina, much less the aging vagina.
I’m seeing more mention of these issues in movies and TV shows. This is important because it normalizes all of these changes. “Grace and Frankie” is a great example of this. This series focuses on a pair of 70-year-old women- an odd couple for sure- who move in together when their husbands leave them. They deal with so many issues as they move on in life, but this show is like a public service message on the menopausal vagina. They openly talk about vaginal dryness, lack of lubrication, and even orgasm. I’ve never seen a show that discussed these topics so openly and so hilariously. And in a way that illustrates how life continues and blossoms long after menopause starts.
There is currently a big campaign going on in the UK to increase education around menopausal changes. The goal isn’t to start everyone on hormones but to educate women on common symptoms and potential treatments. You can check out more here (https://www.menopausematters.co.uk/)
There’s different treatments that can help these irritating vaginal symptoms.
The North American Menopause Society (NAMS) recommends first trying a vaginal lubricant or moisturizer. Many women benefit from a product with hyaluronic acid. There are many different products out there, but I like HYALO GYN (https://hyalogyn.com/). If this does not, estrogen therapy can drastically reduce symptoms. Vaginal estrogen (estrogen that is placed in the vagina) works better than oral estrogen (a pill you take).
There are three different types of vaginal estrogen: a cream, a pill or suppository, or a long-acting ring. Ospemifene is a nonhormonal, oral medication that treats these symptoms as well. Newer data had also demonstrated that vaginal laser therapy could help with vaginal dryness and burning. This is especially exciting for women who can’t use estrogens. Standardized laser protocols are being developed. Laser, while effective, is not covered by insurance and can be very expensive.
Many women like the idea of a bioidentical, compounded estrogen. NAMS and the American College of Obstetrics and Gynecology (ACOG) oppose this type of estrogen. This type of treatment is often linked to hormonal blood testing, which is not needed. There are also more safety concerns and a lack of standardized dosing with compounding. There are FDA-regulated estrogens that are bioidentical to the hormones your body produces.
Vaginal estrogen therapy can also help irritate bladder symptoms like frequently urinating, needing to run to the toilet, and pain with peeing. Some studies have even shown that vaginal estrogen helps more than some medications that specifically target bladder leaking.
Bladder leaking gets worse after menopause.
Bladder leaking becomes more of a problem as we age and definitely worsens after menopause. The bladder gets stiffer and does not hold as well. The urethra sphincter does not close as tightly. Many women link their worsening bladder symptoms to their last period. But we don’t think that menopause causes bladder leaking, only worsens it. The data on estrogen treatment and leaking are complicated and contradictory. Estrogen impacts the continence mechanism in different ways in the different structures. The data shows that the way we give women estrogen doesn’t help urinary incontinence in the long term. This likely means we need more targeted therapy and different delivery mechanisms for estrogen to work. Incontinence in menopause is treated the same way as incontinence before menopause.
Urinary Tract Infections are common after menopause.
Urinary tract infections become more common after menopause. Around 20% of women who are older than 65 get recurrent urinary tract infections or more than three infections per year. The lack of estrogen changes the pH in the vagina, which changes the vaginal microbiome. This means that different bacteria live on the tissue, making it much easier to get bladder infections. The bladder lining also changes after menopause and is less resistant to infection.
Vaginal estrogen therapy (but not oral treatment) has been shown to be a great preventative. It helps prevent urinary tract infections. It will not treat urinary tract infections. The increase in infections that happens with a decrease in estrogen is very surprising to many women.
Menopause can lead to irritative symptoms of the vagina and bladder. Some things in medicine are named poorly, but these irritative symptoms are not. They’re all symptoms that are annoying and bothersome. And you should know that changes in hormone levels cause them. And there are many different ways to treat them.
Alperin M. Menopause 2019
Lee SR J Menopausal Med 2020
NAMS (https://www.menopause.org/)
ACOG (www.acog.org)
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