Menopause & Bladder Leaks—What's Really Going On?

In this episode, I'm diving into a topic that comes up often in midlife: urinary incontinence during menopause. If you've started noticing new bladder symptoms—like leaking, urgency, or increased frequency—you're not imagining things, and you're definitely not alone.

I'll walk through:

• The different types of incontinence and why they matter
• The crucial role of estrogen—and how vaginal estrogen can improve symptoms like dysuria and urge incontinence
• How weight gain in midlife can affect your bladder (and how even modest weight loss can help)
• Why changes in medications or recent surgeries might be affecting your bladder control
• The power of pelvic floor training (yes, it works—and I'll explain how)
• A clear overview of treatment options for both stress and urgency incontinence

Whether you're just starting to notice changes or you've been managing symptoms for a while, this episode is full of practical, evidence-based guidance to help you take charge of your bladder health—without shame or confusion.

Tune in and get the clarity and confidence you deserve.

For more information: a. https://journals.lww.com/menopausejournal/abstract/2023/06000/menopause_hormone_therapy_and_urinary_symptoms__a.14.aspx

b. https://pmc.ncbi.nlm.nih.gov/articles/PMC3038422/#:~:text=Effect%20of%20weight%20loss%20on,of%20noninsulin%2Ddependent%20diabetes%20mellitus.&text=In%20this%20article%2C%20we%20examine,women%20in%20the%20PRIDE%20study.

Timeline:

00:28 Introduction to Menopause and Urinary Incontinence

00:50 Understanding the Prevalence and Types of Incontinence

01:24 Role of Estrogen in Managing Incontinence

02:47 Vaginal Estrogen: Benefits and Usage

05:21 Impact of Weight on Urinary Incontinence

07:42 Medications and Surgeries Affecting Incontinence

08:46 Diagnosing Types of Incontinence

09:09 Pelvic Floor Muscle Training

11:33 Advanced Treatments for Incontinence

12:19 Conclusion and Encouragement

Transcript

 So I am continuing on. Um, my series of podcasts addressing questions that I commonly get asked. And the next one is, what to do about urinary incontinence at the time of menopause. So this is a, a really common question that I get asked. Urinary incontinence becomes more common as we get older.

So it happens in 20 to 30% of young women. It happens in 30 to 40% of middle aged women, and it happens in more than 50% of postmenopausal women. And the type of incontinence changes as we get older. In younger women, stress incontinence is more common, but urgency, urinary incontinence and mixed incontinence becomes more common as we get older.

So when I see someone who is menopausal and we're talking about incontinence, one of the first things that I always think about is their estrogen level. And I will always ask them if their symptoms kind of correlate to when their menopause began, because if the symptoms started with a decrease in estrogen, then it makes sense to me that giving them some estrogen might improve.

So there was a systematic review in 2023 in the Journal Menopause by Monica Christmas and all that looked at this question and they looked at menopausal hormone therapy and urinary symptoms. And what they found is that vaginal estrogen, but not systemic estrogen. So that means estrogen that you put in the vagina, but not.

An oral medication or the patch has been shown to improve dysuria. So dysuria is pain with urination. It has been shown to improve urinary frequency. It has been shown to improve urge incontinence. It has shown to improve stress incontinence, and it has been shown to improve recurrent urinary tract infections as well.

So clinically, if the timing makes sense to me, I think starting with vaginal estrogen makes a lot of sense. There are lots of women who have low estrogen levels, um, that aren't menopausal or perimenopausal. You can also see this, um, if women are breastfeeding or if they're on certain types of breast, uh, birth control.

So it's important, um, to consider those women consider low estrogen in those women as well if they're having these symptoms. Usually when I start estrogen or vaginal estrogen, I will have my patient use it every night for two weeks, and then I just have them use it twice a week after that. Vaginal estrogen is the safest form of estrogen.

It is very low risk if you take it as prescribed because after those first two weeks, um, it really does not increase the estrogen level in your bloodstream. In the first two weeks when the tissue is thinner, sometimes you can feel systemic effects. Sometimes, um, women will have some breast tenderness or they'll feel like they have more estrogen in their system, but after two weeks, that should go away.

And when we've done studies and measure the level of estrogen in the blood, it stays at that menopausal level. So this means that there really isn't exposure, any exposure to the breast tissue or to the uterine tissue. Um, there's a lot more risk, although it also is not high when you take estrogen by mouth or by patch.

Um, this gets a little bit confusing because the vaginal estrogen comes with the same information that oral. Estrogen does, and so that can be really confusing and concerning for women. But in general, we consider vaginal estrogen to be very safe. So because vaginal estrogen is safe and is low risk and helps with so many different symptoms, right?

So pain with urination, urinary frequency, both urge stress incontinence, as well as recurrent urinary tract infection, it, it's something that I will frequently start and then after four to six weeks reevaluate and see how it has impacted, um, the symptoms. The second thing that I think about in postmenopausal women is weight.

So when we gain weight, we're more likely to have urinary incontinence. And this is true for all incontinence, but definitely more true for stress incontinence than urgency urinary incontinence. So with more weight, there's just more pressure on the system, and you're more likely to force urine out. So because weight gain around the time of menopause is so common, this can be a contributor to increasing urinary incontinence.

There've been some studies that have looked at this, and if we look at BMI or body Mass Index, the risk of incontinence goes up by about 10% for each unit increase in BMI. So nobody really likes weight loss or weight gain. Weight loss is hard, but I think this is an important educational point for a lot of women.

The benefit of identifying this is just as weight gain increases incontinence, weight loss decreases incontinence. So there was a study that came out in. Uh, 2010 in the journal ob GYN, that was done by Rena Wing, um, who I actually spent a summer working with when I was in medical school. So I particularly like this research and what she found is that if you lose five to 10% of your body weight, then you're likely to have at least a 70% decrease in urinary incontinence.

Um. That continues. They ask people these questions, um, up to 18 months after their weight loss and the decrease in incontinence continues, which makes, which makes sense. It also depends a little bit on how you gain your weight. Um, if you have more weight in your abdomen, um, versus in your hips, you're more likely to have urinary incontinence.

And there have been some studies that have looked at where fat is and more visceral fat. So more fat around your organs also increases, um, urinary incontinence. So the third thing that I always talk to my menopausal patients about are new medications or new surgeries. Um. And if their symptoms correlate with any changes.

So there are lots of medications that impact bladder function, um, water, pills, diuretics, uh, antidepressants. And then there are some surgeries like back surgery and pelvic. Surgeries that can also impact urinary incontinence. And so when I'm looking for the mechanism, those are always things that I wanna talk to people about.

And sometimes, you know, the, the fix can be as easy as changing our med medication. So, you know, those are the things that I think are a little bit different in my menopausal patients, right? Looking at the impact of estrogen, um, considering weight gain or changes in weight, looking at medications and, um, new surgeries.

And then, you know, at this point. I, um, really wanna make the diagnosis. So I wanna know if they have stress incontinence, urgency incontinence, or mixed urinary incontinence. And usually I can do that on history. Um, sometimes I have to use some, um, specific questionnaires to diagnose it. Sometimes we do some testing in the office if it really, um, isn't clear.

And you know, the first thing that we recommend is pelvic floor muscle training at this point in time. So there was a meta analysis that came out by Chantel Duma in, um, 2018. Um, it was a Cochran. Review, they looked at 31 trials. Um, there were more than 1800 women from 14 countries in these trials, and what they found is that with pelvic floor muscle training, if you had stress incontinence, you were eight times more likely to be cured versus doing nothing.

So. Public floor muscle training is particularly beneficial for women that have stress incontinence, and if you had any urinary incontinence, you were five times more likely to be cured versus no treatment for patients with mixed urinary incontinence. There was also an increase in quality of life that was shown for stress incontinence.

Um, there was a significant improvement in urinary incontinence symptoms as well as. An increase in quality of life. So pelvic floor muscle training can cure or greatly improve urinary incontinence in lots of women. And I think this is particularly important, um, in menopausal patients because of the risk of muscle atrophy or muscle wasting.

So as we get older, our muscles start to waste. This happens to everybody. It generally starts at. Age 30 and your muscles will decrease by three to 8% per year. And so this means by the time you are 50, you may have a decrease in your muscle bodies that are. You know, six to 16% less than when you were 30.

And with small muscles like your sphincter, you may start having symptoms because of that. So I think doing pelvic floor muscle training at this point, um, is super important. Because it can cure the incontinence, but it is also setting you up to good habits, worsening incontinence in the

take some. You know, if these measures at this point in time, you know, haven't helped you achieve the benefit that you want, then um, you know, we would be looking into, you know, kind of the normal treatments for stress incontinence, um, and for urgency incontinence, depending on. Which type of leaking you had.

So you know, that might be a pessary or a bulking agent or a surgery. Um, it might be a medication, it might be Botox in your bladder. It might be a nerve stimulation. There are lots of different things that we can do, and those are treatments that I have talked about. In general, they can absolutely be used in menopausal.

As well. I just wanted to talk to you a little bit about the things that are a little bit different at this point in time that we should be thinking about as well. I hope that was helpful to you. If you're having any problems with leaking, I definitely encourage you to, um, seek professional help, get started on some pelvic floor muscle training, um, and think about these other factors as well.