urogenital symptoms in menopause

Urogenital symptoms in menopause – your ultimate guide

Urogenital symptoms in menopause affect over 65% of women over the age of 60 years and signs gradually worsen with age. The main symptoms are of vaginal dryness, irritation and pain with intercourse. Pain and burning with passing urine, frequency and urgency are common bladder symptoms. Irritable bowel like symptoms also occur around the time of menopause.

How menopause affects the urogenital system and what to do about it

Did you know…

  • Over 65% of women over the age of 65 suffer with vaginal dryness which is named as one of the most bothersome of the urogenital symptoms in menopause.
  • One in three women will experience urinary incontinence at some point in their lives and particularly as they go through menopause.
  • Only 20 – 25 % of women actually seek help for their problems with vaginal dryness, painful intercourse and bladder leakage and even fewer for bowel related problems as they go through menopause.
  • Over 60% of women who do seek help do not get the treatment they need even though it is easily available and evidence-based.
  • 50% of women over the age of 50 will stop having intercourse because of urogenital symptoms in menopause.
  • Urogenital symptoms in menopause in particular vaginal dryness and painful intercourse affects sexual function and can cause relationship difficulties
  • Significant skin changes of the vulva at menopause are never discussed and can lead to cancer if not diagnosed or treated correctly.
Urogenital symptoms in menopause are bothersome and significantly affect quality of life


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Here is a summary of urogenital symptoms in menopause that we will discuss in this article

Menopause and vulvovaginal atrophy (including vaginal dryness, irritation, pain with intercourse and urinary symptoms) – also called genitourinary syndrome of menopause

Bladder problems in menopause

Pelvic floor dysfunction in menopause and prolapse

Vulval skin changes in menopause

Bowel problems in menopause

Suffice to say that urogenital symptoms of menopause are extremely common and significantly affect a woman’s quality of life.  In each section I will highlight the common symptoms that women face. If you identify with any of them, please see your doctor and seek help for them. It is important to talk about your problems so that you can get the help you need – this is available and effective in relieving much of the distress these problems cause.

Causes of urogenital changes at menopause

There are two main reasons for these changes.

One is the decreasing estrogen levels in the body as a woman goes through menopause which is defined as when she stops having periods for 12 months in a row. The eggs in the ovary are depleted over her reproductive life span and menopause signals the time when there are either no eggs or too few eggs left in the ovary.

This means that the hormones which are normally produced as part of the process of ovulation are not produced. The most important hormone is estrogen, although several other hormones are also affected e.g., progesterone, testosterone, DHEA, oxytocin, cortisol.

The second reason is the progressive changes that happen with ageing and illnesses that become common with ageing. These are obesity, hypertension, diabetes mellitus, effects of pregnancy and delivery and the effect of several medications that a woman might be taking (diuretics and sedatives). Surgery such as a hysterectomy can also aggravate these changes.

Risks of incontinence as we age

You don’t have to live with incontinence – get help


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Incontinence is often described as a dreaded part of ageing and it doesn’t have to be that way.

Both urinary and fecal incontinence worsen with ageing and for many women it can start around the time of menopause. One in two adults over the age of 80 has incontinence of either bladder or bowel or both.

The measures to prevent incontinence and its problems needs to be addressed several decades before it happens. This means that we need to put in place the habits and behaviours that can prevent incontinence or reduce its impact on our quality of life even before we become menopausal.

So, if you remember how to do your pelvic floor exercises it is probably time to start doing them again now rather than wait for bladder and bowel symptoms to start.

It also means that we need to get access to and use the treatments that are available to us to do this.

Incontinence isn’t just inconvenient. It has several other health issues associated with it.

  • Incontinence affects the skin of the genitals and can cause irritation and ulceration that doesn’t heal easily.
  • Incontinence results in a need to wear diapers / nappies / incontinence pads that cause chaffing and skin damage especially when needed to be worn constantly.
  • Some women may need to learn to catheterize themselves or need a catheter long term to manage incontinence. This results in risk of infection and bladder or kidney damage.
  • Incontinence can result in leaking accidents which can aggravate falls and hip fractures – a major cause of death in women over the age of 65 years because of osteoporosis.
  • Social isolation and depression – women who leak or feel uncomfortable if they are not near a toilet can isolate themselves and stop socializing. It can cause intimate relationships to break down. This worsens depression and anxiety and is another major cause of death and a suicide risk.

You can see now why it is so important to understand the effect menopause can have on urogenital health and why it is important to prevent incontinence and if it occurs to get help soon.

What is genitourinary syndrome of menopause – which symptoms bother women the most?

‘Genitourinary syndrome of menopause’ was a term coined in 2014 to describe the changes that happen to a woman’s genitals because of the dropping estrogen levels at the time of menopause.

The symptoms that are included in this syndrome are:

  • Vaginal and vulval dryness
  • Irritation, burning or itching of the vagina and vulva
  • Decreased lubrication with sex
  • Pain or discomfort during sex
  • Bleeding after sex due to small tears in the vagina or vulva
  • Loss of desire or ability to feel aroused or have an orgasm
  • Burning or pain when passing urine
  • Needing to pass urine frequently or wake up at night frequently to pass urine

When your doctor examines you, these are the signs that suggest lack of estrogen in the system:

  • Thin parchment like vagina that is pale and tears easily
  • Dry vagina that doesn’t have moisture and is not elastic
  • Loss of the normal vaginal folds leading to shortening and shrinking
  • Small tears and bleeds when inserting a speculum
  • Flattened cervix and difficulty obtaining a cervical smear
  • Loss of the architecture of the labia minora (the small lips)
  • Retraction of the clitoris and even resorption (cannot see the clitoris even after retracting the labia)
  • Prolapse or protrusion of the urethral opening
  • Tightening or narrowing of the urethral opening
  • Shrinking or tightening of the introitus – the entrance to the vagina
  • Shrinking or flattening of the hymen
  • Change in vaginal pH and presence of inflammation (this used to be called atrophic vaginitis)
  • Change in vaginal odor because of infection or altered vaginal flora or incontinence
  • Vulval skin changes – thin parchment like, thickened plaques, infections such as candida and tinea, moles, folliculitis (infection of the hair follicles), damage to skin from leaking urine
  • Anal skin changes, piles, fissures and a narrowed perineum (the distance from the introitus to the anus decreases as we age and the risk of infection from the bowel increases)

Of all these symptoms it is vaginal dryness and irritation that is one of the most bothersome symptoms of the menopause, second only to hot flashes.

Vulvovaginal atrophy – vaginal dryness, irritation, painful intercourse

Vaginal dryness, irritation and pain with intercourse are bothersome symptoms of menopause


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As women go through menopause, they experience problems like vaginal dryness, itching, irritation and discomfort. This is felt in day-to-day activities and especially in relation to sexual activity and bladder problems.

The lack of production of estrogen by the ovaries causes the skin of the vulva and its architecture to become thin and shrunken and less elastic. The glands that normally keep the vulva soft and moist dry up. Even getting aroused doesn’t produce the same kind of lubrication as it used to before menopause. This is because the glands which normally produce the lubricating fluid dry up without the effect of estrogen.

We now know that estrogen receptors are present throughout the genitals in women – the vulva, vagina, cervix, perineum, anus, bladder and bowel.

The labia can shrink and the clitoris can become either exposed and hypersensitive or buried under fused and shrunken labia.

Many women find that the appearance of the vulva changes and this can affect their self-esteem. The fat pad may become prominent on the mons and the labia can become flabby. If the outer lips thin out too much the inner smaller lips can become prominent and cause discomfort when they rub on underwear or get pulled during intercourse.

Thinning of the skin of the vulva can cause pain and discomfort with sex and even cause small tears that bleed easily.

The vaginal pH changes and there is an increased risk of infection and an altered discharge that can become smelly. Infections can add to the sensation of burning and irritation.

Many women try a variety of home remedies like olive oil, coconut oil and combinations of almond oil, jojoba oil or aloe vera. There are a number of herbal preparations that can help too.

The most effective treatment is of course vaginal estrogen. This is often administered as tablets, gels, creams or rings inserted into the vagina. Vaginal estrogen is safe and highly effective at reducing the distress caused by symptoms of vaginal dryness.

Some women cannot use vaginal estrogen for a variety of reasons. One of the main ones is recovery from hormone dependent cancers. The chemo and radiotherapy can cause severe vaginal dryness and irritation. A variety of medications have been researched and are approved for use by such patients.

Some newer medications are Ospemifene and Bazedoxifene. Lasers have also been found to be useful to treat vulvovaginal dryness and atrophy in cancer patients.

You can read more about vaginal dryness and its management in this article

Sex and menopause

Vulvovaginal dryness and atrophy can severely affect comfort and enjoyment of sex. The vagina doesn’t lubricate as well and getting aroused can take a lot of effort.

Many women give up being sexually active after the age of 50. Loss of desire, arousal and difficulty with getting an orgasm, difficulty communicating about changing needs and age-related stress can significantly impact relationships.

The psychological symptoms of menopause can trigger angry outbursts and problems in the bedroom can blow up into relationship stress.

Add to this the symptoms of hot flashes, body ache, palpitations, heavy periods, anaemia, anxiety and depression and you can see how intimacy and sex are easily sacrificed in the day-to-day struggle to manage health issues relating to menopause.

You can read more about sex and menopause in this article

Urinary bladder problems in menopause

Normal bladder function is represented by:

  • A daytime frequency of 4-6 and night time frequency of 0-1.
  • Approximately 1-2 cups of urine (250 – 500 ml of urine passed at a time).
  • Able to control passing urine till a suitable time and place is available.
  • The stream of urine is steady and the flow is continuous till the bladder is emptied.
  • The bladder can be emptied completely.
  • There is no leakage of urine in between toilet visits even at night.
Overactive bladder symptoms include frequency, urgency, nocturia and leaking


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When estrogen drops through menopause many of these functions change. As we age, many factors can weaken the pelvic floor muscles responsible for bladder control resulting in urinary incontinence. This includes damage during pregnancy, childbirth, and weight gain.

The common urinary symptoms women complain about at menopause are:

Nocturia

This means getting out of bed several times to use the bathroom at night.

Painful urination or dysuria

A burning or stinging sensation when passing urine.

Stress urinary incontinence

Leakage of urine that occurs during sneezing, coughing, or heavy lifting.

Urge incontinence, overactive bladder, irritable bladder

Also known as overactive bladder or irritable bladder. Urge incontinence is the leakage that occurs when the bladder muscles squeeze seemingly at random or just all the time. This may or may not be associated with a sensation of urgency. For many women the bladder can just empty itself without warning and this is part of the symptom complex of overactive bladder and menopause.

Mixed incontinence

This is where there is some amount of urgency associated with leaking just before coughing or sneezing or just after. The picture is not clear cut with both urge incontinence and stress incontinence occurring at different times. Often a urodynamic study is required to get a diagnosis especially if surgery is being considered for stress incontinence.

Other symptoms that women complain of can be:

Urgency

Urgency is the sensation of wanting to go to the bathroom with anxiety that a leak might happen. Urgency may not always be associated with leaking. Many women manage their symptoms by increasing the number of times they visit the bathroom – this is called Frequency.

Frequency

Needing to go to the bathroom more often than usual. This can be in the daytime or night time. Many women cope with incontinence by keeping the bladder empty by going frequently. Urine infections can also cause frequency by creating a sensation of pain or urgency.

Incomplete emptying or incomplete voiding

This is when the bladder does not empty completely. It can be because of prolapse – where a part of the bladder balloons out of the vagina and straining to pass urine often worsens the bulge causing urine to be left behind. Typically, you feel like going back to the bathroom soon after you have been and are still able to pass some urine. A bladder with residual urine (urine left behind after emptying the bladder) becomes a reservoir for bacteria to grow in.  These are often bacteria from the bowel – E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia.

Recurrent urinary tract infections / recurrent UTI

Recurrent urinary tract infections need a thorough assessment


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Recurrent urine infections are the bane of the menopausal bladder. The lack of estrogen causes even the bladder wall to lose its resistance to infection and become thinned out. The most common cause is incomplete emptying of the bladder.

Symptoms of a urine infection can be frequency, urgency, pain, fever, cloudy colored and smelly urine, pain in the lower abdomen and if the infection tracks up to the kidneys – pain in the flanks and loin area.

Recurrent urinary infections are diagnosed on urine microscopy and culture. More than three infections with the same organism in one year is classed as a recurrent infection. The treatment is with antibiotics and treating the cause which may include surgery to correct prolapse. Vaginal estrogen is very helpful in preventing recurrent urinary infections in menopausal women.

Straining to empty

When the bladder doesn’t empty completely it is natural to feel like straining. This often worsens the situation because of the structure of the female urethra. With menopause, the urethra also becomes thin and narrow and this can cause problems with emptying the bladder. Occasionally, prolapse can cause kinking of the urethra and straining can worsen the prolapse and make passing urine even harder.

Needing to replace the bladder to empty it

When the bladder balloons out into the vagina – called anterior vaginal wall prolapse it can collect urine and also kink the urethra. As the prolapse worsens, the woman may need to put her fingers into the vagina to replace the prolapse before she can empty her bladder.

Enuresis

This is wetting the bed when asleep. There can be a number of reasons for this including infections and the effect of sedative or diuretic medication used to treat other conditions.

Leaking urine continuously

This can happen due to a fistula which is an open connection between either the bladder, urethra or ureters to the outside – most commonly following surgery or radiotherapy. In younger women this would commonly be following a traumatic or complicated delivery.  Urine most commonly leaks into the vagina but it can also leak through the cervix or out to the skin of the vulva or through the urethra. Rare neurological conditions can cause continuous leaking. This needs investigation and several additional tests to determine where it is coming from. Treatment is usually surgical.

We have seen how incontinence can adversely affect quality of life. Urinary incontinence affects over 50% of post-menopausal women. As the ageing population increases the sheer number of women suffering with incontinence is predicted to rise exponentially. The cost of managing incontinence is estimated to be over $13 billion worldwide.

Sleeplessness, nocturia, frequency and urgency increase distress in menopause


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Pelvic floor dysfunction and menopause

Pelvic floor changes and uterine prolapse symptoms

As menopause sets in some women may feel

  • a sense of ballooning or pressure or bulging in the vagina.
  • Sometimes they can even feel the cervix protruding outside the vagina if they strain at urine or stools.
  • Others may get a low backache the longer they stand and a general discomfort and dragging sensation in the lower abdomen.
  • Some women may notice a bulge in the vagina that needs replacing with fingers to allow them to pass stools or urine.
  • Sometimes prolapse can get in the way of intercourse and make sex uncomfortable or painful.
  • Rarely with advanced prolapse the protruding part can get ulcerated and bleed on touch or when rubbed by underwear.

All these are symptoms of uterovaginal prolapse or prolapse in common terms.

Causes of uterovaginal prolapse

We already discussed how the pelvic floor muscles, ligaments and genital structures have estrogen receptors. As estrogen levels decline throughout the body, collagen and elastin production decreases and existing tissues do not get repaired the same way as before menopause. This results in reduced tone and strength in the pelvic floor allowing the process of prolapse to take place.

Usually, pelvic organs can start to get displaced or ‘fall out’ because of damage to the ligaments and muscles that support the pelvic organs. This damage can happen during the following:

  • pregnancy and childbirth
  • menopause with decreasing collagen and elastin
  • persistent coughing or chronic constipation
  • heavy lifting or prolonged standing with straining
  • surgery that damages pelvic nerves or ligaments and muscles
  • a tumor or mass in the abdomen or even fluid (ascites) can precipitate a prolapse

About half of post-menopausal women have a bulge in the front wall of the vagina, a quarter of the back wall and about 20% with the top of the vagina or cervix. If prolapse of the top of the vagina happens after a hysterectomy it is called a vault prolapse.

Treatment of Uterovaginal prolapse

Treatment of prolapse depends on the severity and type of prolapse and the effect it has on quality of life.

Non-surgical treatment of prolapse

This includes pelvic floor exercise and physiotherapy, vaginal pessaries and vaginal estrogen treatment.

Surgical treatment of prolapse

The type of surgery offered depends on the prolapse itself, age of the patient, previous surgery, associated bowel or bladder problems.

Reconstructive surgery aims to repair and replace the prolapse to its original position so that organs like bowel and bladder work as normally as possible. This may sometimes mean removing the uterus and cervix to allow a proper repair to be performed. Sometimes such repair may need a material like a mesh (synthetic or patient’s own tissue) to be used to support the prolapsed vagina. Surgery can be done vaginally, abdominally or endoscopically.

Vaginal closure surgery is done in very infirm or elderly patients who cannot tolerate anesthesia or a major operation and are not sexually active. This usually involves pushing the prolapse back inside and closing the opening of the vagina.

Vulval skin changes in menopause

The skin of the vulva undergoes several changes in menopause. Decreasing estrogen levels means it becomes drier and less flexible. Vulval changes can be because of estrogen decline or because general skin changes in the body also affect the skin of the vulva.

Some common vulval problems are:

Vulvodynia


Vulval pain can cause physical, emotional and sexual problems

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This is a condition where there is pain over the vulva. It can be throbbing, burning, stabbing or a sharp cutting pain.

The pain can be constant or come in waves and episodes.

The triggers could be a Herpes simplex infection, other sexually transmitted infections, trapped nerves following surgery or most commonly unknown reasons.

The decreasing estrogen levels in menopause can also trigger attacks of vulval pain and the frequency of attacks can increase during menopause.

Treatment is of the cause and associated psychological effects of chronic pain. Women often need counseling and support for partners is also encouraged.

Lichen sclerosus

Lichen sclerosus is a chronic skin inflammation that shows up as white scarred plaques. These can be painful and cause intense itching. Scratching can damage the skin further and get secondarily infected with bacteria. No one really knows the cause of this condition. The vulva can become scarred and papery and is easily damaged. Sex can become very painful and it is often accompanied with bladder problems. Rarely there is a risk of cancer in the skin affected by Lichen sclerosus.

It is important to never self-treat vulval skin conditions. Most over the counter preparations contain steroids and this can alter the appearance of the skin should a biopsy be needed.

Vulvoscopy is an examination of the skin of the vulva under a microscope. A mild solution of acetic acid and toluidine blue is used to study the cells under a microscope similar to a colposcope that is used to study the cervix.

Most gynecologists will do a small biopsy of the skin of the vulva to confirm the diagnosis and rule out cancer before prescribing local steroid creams to prevent the disease from progressing.

Lichen planus

This is a condition that affects the skin of the body particularly the mucous membranes. It can affect the vulva and vagina too and appears as purplish, itchy bumps on the vulva and white patches on the vagina.

This usually goes away on its own and may be triggered by stress and anxiety. Treatment is with topical creams after a vulvoscopy or biopsy.

Candida and other fungal infections

Fungal infections are common in the genital area because it is moist and warm. The pH of the vulva changes as a woman goes through menopause. The normal pH is acidic (between 3.5 – 4.5). When the pH changes and the skin becomes thinner and less moist, it becomes vulnerable to infections.

At the menopause women are also likely to suffer with diabetes mellitus that makes getting fungal infections much more likely. Treatment is with local creams or powders and oral antifungal tablets. Because of the nature of fungal infections treatment can be prolonged.

Folliculitis

We have already discussed how the pH of the vulva changes as estrogen levels decline. The hair follicles on the pubic area also become dryer and the glands that normally lubricate the hair shaft also become dry. They can get infected easily with bacteria from the bowel and result in inflammation called folliculitis.

Shaving or hair removal can aggravate this problem.

It is best to just trim the hair with a hair trimmer rather than shave. If the hair poses a big problem it is probably better to opt for laser hair removal rather than shaving or hair removal creams or waxing.

Other skin conditions affecting the vulva

Other skin conditions can affect the vulva as well. E.g. psoriasis, dry skin conditions, bacterial skin infections, warts, herpes, sexually transmitted infections and their skin manifestations.  The list is quite extensive.

It is very important to see your doctor for the correct diagnosis and to not self-treat.

Cosmetic procedures

Many women suffer with low self esteem due to changes in the appearance of the vulva as they go through menopause.

Various treatments that are included in vulval cosmetic surgery include laser vulval skin lightening, labiaplasty, clitoroplasty, labial fat infusion and mons pubis remodeling.

Vulval hygiene and skin care

The skin of the vulva is delicate and becomes fragile with lack of estrogen and ageing. The following skin care tips will be useful in keeping your vulva healthy.

  • Wash the vulva with tepid water – avoid hot water as it dries out the skin too much.
  • When you wash yourself make sure you wash from front to back. This is to avoid contamination with bowel bacteria. As you go through menopause this contamination is much more likely to cause persistent infection in the vagina and bladder.
  • Avoid using body washes or soaps on the vulva – they are alkaline whereas the pH of the normal vulva is acidic. Use a wash that is specifically designed to be used on the vulva and is pH balanced for that purpose.
  • Avoid using deodorants or perfumes on the vulva. If you think the area is smelly or the smell has changed get a check up from your doctor to rule out infections or other causes of a smelly discharge.
  • Prefer to use cotton underwear and clothes that are light and airy. Avoid using tight or synthetic clothes that encourage sweating. At night you may wish to go without underwear.
  • You can use home made moisturizers or lubricants made with olive oil, coconut oil and aloe vera to soften and moisturize the vulval skin. If you do not get relief see your doctor.
  • Avoid buying medicine or creams over the counter to treat your vulval dryness and itching. Using these can change the appearance of the skin if a biopsy is required and it can be harder to reach a diagnosis.

Bowel symptoms in menopause

The decreasing estrogen levels of menopause affects all the systems of the body and the gastrointestinal system is no different. Right from the mouth to the anus, all parts of the gut are affected by decreasing estrogen levels.

Does menopause worsen irritable bowel syndrome?

Menopause can worsen symptoms of irritable bowel syndrome


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As they go through menopause, many women can vouch for the changes in digestion and bowel movement they experience.

  • Food they used to enjoy no longer tastes the same and the stomach is not as resilient as it used to be. Food intolerance becomes much more noticeable.
  • Dry mouth and burning mouth of menopause is a well-known phenomenon. Digestion of food starts in the mouth and this is compromised because of a decrease in saliva, tooth and gum problems.
  • Gut motility changes because of changes in how the sympathetic and parasympathetic system behave in the face of decreasing estrogen levels.
  • Stress and lack of sleep at menopause can push cortisol levels up. This affects the microbiome in the gut and the vagina and vulva.
  • Gut secretions and behaviour of bowel secretions is altered and irritable bowel syndrome symptoms can worsen because of this.
Bowels symptoms in menopause can cause isolation and depression

Let us look at some symptoms that tend to occur around the time of menopause or get worse as you age.

Fecal urgency

Needing to rush to the toilet to pass stools. This can be worsened in irritable bowel syndrome when the stools are loose and diarrhoea makes holding on to stools much more difficult.

Fecal incontinence

This is the inability to hold on to stool long enough to reach a toilet to pass them. Incontinence may result as a long-term complication of anal sphincter injury at the time of childbirth.

Occasionally it can occur with diarrhea or medication used to relieve constipation. Fecal incontinence can be mild or severe depending upon the cause. If the cause is related to poor sphincter control the leak may only be small amounts noticed on underwear.

However, if it is associated with irritable bowel syndrome and autonomic dyssynergia (imbalance of sympathetic and parasympathetic system) the rectum can end up contracting and emptying its entire contents. This condition is very similar to overactive bladder in its manifestation.

Flatus incontinence

Flatus incontinence is the inability to hold wind. Normally the rectum and anus are very sensitive and have the ability to differentiate between solid and gaseous contents. The higher centers in the brain can control when and where it is appropriate to permit liquid, solid or gas to pass through the sphincter.

If the anal sphincter is damaged during childbirth or nerve damage following pelvic surgery affects the function of the sphincter, flatus incontinence can be the first sign of something not quite right.

Constipation

The other end of the spectrum is constipation. This often occurs for the first time as women go through menopause. The drying effect on gastrointestinal secretions and changing gut microbiome means that food does not get digested as well as before and does not pass through the bowel easily either. Gut motility might slow down worsening the symptom of constipation.

Add to this a weakened pelvic floor and poor rectal sensation – this can cause a delay in emptying the rectum and complicate constipation.

Anal piles and fissures

Chronic constipation and straining at stools can cause piles or haemorrhoids to occur. When the mucosa of the anus is damaged it results in a painful condition called anal fissure. This is much more common in menopause because of the dryness and atrophy that takes place in the genital area.

Anal piles and fissures may respond to medical treatment if diagnosed early. If treatment is delayed surgery may be needed to reduce pain and discomfort.  

Management of urogenital symptoms

Urogenital symptoms are very common as you go through menopause. You should not ignore these problems because they rarely go away and usually get worse over time. They often interfere with work, social activities, and sexual and personal relationships. It is important that you seek help from your doctor in time because these problems can be cured, treated or better managed. 

Even though you may assume that the menopause is responsible for your symptoms, your doctor will rule out other possible problems too.

I have talked in more detail about how to make the best of your physician consultation towards the end of this article.

History taking

Your doctor will need to take a detailed history of the urinary symptom and how your bladder behaves in different situations. The same is true for bowel related symptoms.

Women are usually much more reluctant to talk about bowel problems, but it is important to discuss them because menopausal changes can affect both bowel and bladder and treatment of one can make the other worse. For example, medications used to treat overactive bladder can cause a dry mouth and constipation. Medication used to treat depression can cause gut motility issues.

Examination and Tests

A physical and pelvic exam comes next. It is normal to perform a cough or stress test when doing a pelvic exam to test for urinary leakage and to check for prolapse. Urine is sent for microscopy and culture to check for infection. The doctor may also do an anal examination if your symptoms include fecal or flatus incontinence or piles and anal fissure.

Additional tests can be asking you to keep a bladder diary, a pelvic ultrasound examination, an Xray of the kidneys and bladder if required, a pad and dye test if suspecting a fistula, cystoscopy and urodynamic studies if surgery is being considered.

For bowel related problems a stool examination and a colonoscopy, anal manometry (measurement of pressure changes in the anus and anal sensation) and a special Xray called a defecography may be needed. Endoanal ultrasound can detect structural damage to the sphincter.

Treatment

Women with bladder or bowel control problems have a wide range of treatment options available to them, based on the type of incontinence and severity. There are many medical and non-medical recommendations for managing these problems. Again, talk with your doctor about which options work best for you.

The International Continence Society Guidelines recommend conservative treatment to start with. This should include pelvic floor physiotherapy, pharmacotherapy and behavioural therapy.

Lifestyle recommendations

Drink at least 1.5 – 2 litres of water to help prevent constipation


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  • Eat a healthy diet rich in dietary fibre to prevent constipation. We need at least 30gm of fibre each day. Eat at least 2-3 serves of fruit, 5 serves of vegetables and 5 serves of grain, beans or lentils.
  • It is important to get the balance right as just adding fibre to your diet without increasing your fluids can cause or make constipation worse. If the steps outlined in this section do not solve an ongoing constipation problem, talk to your doctor.
  • Drink water – Drink 1.5 – 2 litres of fluid each day to prevent bladder irritation and constipation, unless otherwise advised by your doctor. Drinking extra fluids is recommended in hot weather or when exercising. Spread your drinks evenly throughout the day. Water is best
  • For obese women, losing weight and maintaining a healthy weight may increase bladder control.
  • Avoid caffeine, alcohol, carbonated drinks and diuretics that trigger urgency and leakage.
  • Improving general physical fitness can be a challenge if stress incontinence is an issue. There are several pessaries and tampons that can be used to support the bladder neck so that exercise need not stop. Keeping fit certainly makes a difference to the management of bladder problems, menopause in general and quality of life.
  • Managing fluid intake, alcohol and medications to suit lifestyle so that most bladder activities are completed before bedtime.
  • Double voiding – learning to empty the bladder by passing urine twice is very effective at keeping infections at bay.
  • Perineal hygiene – learning to keep the vulval area clean and dry. It is important to clean from front to back and to dry the area before putting on underwear. This helps to avoid the bowel bacteria from colonizing the vulva and urethra.
  • Neuropathy is a common complication of diabetes mellitus. Nerves to the bladder and bowel can be damaged causing loss of sensation, poor emptying and constipation. Keeping your diabetes well controlled is the best way to prevent or stop nerve damage.
  • Practice good toilet habits: Go to the toilet when your bladder feels full or when you get the urge to open your bowels. Do not get into the habit of going ‘just in case’. Take time to completely empty your bladder and bowel.
  • Correct toilet position: sit comfortably on the toilet, with elbows on knees, feet on a footstool. It is important to empty the bowel or bladder completely. Avoid ‘hovering’ over the toilet seat because you think it might not be clean if you are using a public toilet. It is better to carry a sanitizer and tissue to clean the seat.

Bladder training 

Bladder training helps you to hold on to your urine by gradually increasing the time you hold on before going to the bathroom. Over a period of 4-6 weeks, you can train your bladder to hold more urine for longer by using timed emptying to give yourself a feeling of control.

Local estrogen – does estrogen help menopause bladder symptoms?

The answer is yes!

Vaginal estrogen treatment with creams, tablets, gels or rings is very effective at reducing the symptoms of irritable bladder such as urgency, frequency, nocturia and recurrent urinary infections.

For women who cannot tolerate vaginal estrogen a number of alternative treatments such as vaginal oxytocin gel, laser treatments and oral ospemifene have been suggested.

There is not enough data to suggest whether vaginal estrogen therapy is useful in the management of fecal incontinence.

Hormone Replacement Therapy

As lack of estrogen is the primary cause of urogenital atrophy, the treatments for it in postmenopausal women involve low-dose hormone replacement therapy (HRT). These can help restore the vagina to premenopausal condition and relieve many symptoms of urogenital atrophy. If systemic estrogen therapy doesn’t improve bladder function, additional vaginal estrogen is sometimes prescribed.

There are newer medications like Bazedoxifene and Ospemifene that have been trialed.

Prescription medication

Anticholinergic medication is used to decrease overactive bladder symptoms (Tolterodine, oxybutynin, solifenacin, darifenacin, mirabegron). Drugs like Duloxetine are used to manage mild symptoms of stress incontinence. Drugs like alpha blockers are often used in women who have a narrowed urethra and need to strain to pass urine.

Antibiotics may be required to treat recurrent urinary tract infections in addition to managing the voiding problems and prolapse which may be the real reason why the infections keep happening.

Drugs used to treat overactive bladder can worsen dry mouth and constipation. It is worth keeping a diary of symptoms to report back to your doctor with the side effects of medication you are taking.

Pelvic floor exercises and pelvic floor physiotherapy

Pelvic floor exercises can strengthen the pelvic floor reducing the risk of uterovaginal prolapse and improving symptoms of urinary leakage. Many women have learnt these techniques from childbirth, but it is well worth revisiting them.

Pelvic floor physiotherapy is the first line therapy for both stress urinary incontinence and urge incontinence and makes a significant difference to treatment outcomes even if you need medication or surgery.

Pelvic-floor physiotherapists are specialists with expertise in assessing pelvic floor function involved in continence – both urinary and bowel. They are able to assess and monitor a woman’s 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, biofeedback machines and electrical stimulation if pelvic floor muscle tone is poor.

Medical devices

A pessary is often inserted into the vagina to support the bladder neck or also to support a prolapsed uterus.  The pelvic floor needs to have good enough tone for pessaries to work effectively.

Nerve stimulation devices

Sacral neuromodulation is a treatment used in cases of overactive bladder which have not responded to other conservative measures

Botox

Botox injections into the bladder wall help to relax it over a period of 6-8 weeks. In patients with overactive bladder this can either completely relieve symptoms or allow sufficient time for bladder retraining to become an established habit which can relax the bladder muscles.

Surgery

If surgery is required to treat stress urinary incontinence (sling surgery or colposuspension) or surgery to treat a fistula, a more detailed assessment with a computerised test called urodynamics is performed. This gives a better idea of the likelihood of success of surgery and the possibility of side effects or disadvantages. Much of this surgery is now done with minimally invasive techniques using endoscopy.

Piles or hemorrhoids and anal fissures may need surgery if they do not respond to medical treatment (usually local anesthetics, antibiotics and stool softeners).

Discussing bladder and bowel problems with your doctor…

How to talk to your doctor about urogenital symptoms in menopause?

Most women, even doctors, feel embarrassed to talk about intimate problems relating to the bladder bowel or sex. It is easy to turn up to your appointment unprepared and miss out important subjects that need attention. This is particularly important because bowel and bladder problems that arise at the time of the menopause do not get better – rather they tend to get worse with age. The earlier you get diagnosed and treated the better it is for your overall health and quality of life.

Here are some tips for discussing “embarrassing” problems with your physician:

  • Make a list of what you want to discuss and how the problem affects you
  • Discuss the most important or most difficult questions first. You may find that your doctor is only willing to discuss the first point on your list due to time restrictions. Make sure the first point is the most important or the one that causes you most distress.
  • Take someone with you that can write down what the doctor says or listen to important points for you.
  • Write down what the doctor tells you
  • If there is anything that you don’t understand, ask for clarification
  • If you doubt being able to put your problem into words take some printed material with you. This could be a magazine article or information from a website on the internet.
  • If you feel embarrassed, practice talking to your doctor in front of a mirror or do a role play with a friend. Repeat 3-4 sentences till you feel comfortable saying them.
  • If you still feel unable to discuss the subject, write it all down and hand it to the doctor
  • Make a list of details you want the doctor to know and give it to the doctor. This can include your symptoms, the effect it has on your quality of life, other illnesses, medication you are currently taking, any other over the counter medications or alternative treatments you have tried and whether they worked or not.

Conclusion

Urogenital symptoms in menopause can significantly affect quality of life. Majority of the problems relating to bladder, bowel and vaginal dryness are not life threatening but they can seriously affect everyday activities of living.

Almost 65% of women over the age of 60 years will suffer with bowel and bladder problems related to the menopause and decreasing estrogen levels. Less than 25% will seek help for these and less than 40% get the treatment they need. This happens even though effective treatment is available for all genitourinary problems and they can be treated or managed so that they do not affect every day life adversely or deteriorate with time.

Most women are embarrassed to speak to their doctor about their problems and this delay in diagnosis and treatment can cause the problem to deteriorate significantly. If caught early, treatment is simple and can even cure the problem.

If any symptoms in this article have caused you to think about your own bladder and bowel symptoms or symptoms of vaginal dryness, I would encourage you to write them down and book an appointment to see your doctor as soon as you can. Take the tips above into consideration when you get your appointment.

Do write to me at masterthemenopause@gmail.com  about what you liked in this article and whether it helped you address some of your concerns.

Look out for more content related to topics in this article as I will be diving deeper into them in future posts.

References


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