Understanding Hormones and Bladder Health

Hormones play a bigger role in bladder health than most women realize. In this week's episode of "while you wait…" podcast, I break down how estrogen shifts during perimenopause, menopause, postpartum, and even certain birth control methods can affect urgency, leaking, and pelvic floor function. I also explain why vaginal estrogen may be part of the solution, common risk factors for incontinence, and how lifestyle factors like weight, sleep, and stress can make symptoms better or worse.

Timeline:

00:30 Introduction and Overview

01:04 Hormonal Changes and Bladder Health

04:50 Genetic and Risk Factors for Incontinence

07:31 Non-Hormonal Factors Affecting Incontinence

09:28 Communicating Symptoms with Doctors

12:40 Hormone Therapy and Bladder Symptoms

15:15 Conclusion and Final Thoughts

Transcript

Hi there. I frequently get asked to comment on different products or to offer my opinion on incontinence and things you can do, things that might make be making it worse. And I recently was asked to collaborate for an article for Flow Space, and they were interested in discussing how hormones and hormone therapy impact bladder health.

They asked so many great questions during this interviewing process that I thought it would be helpful to make an episode around this topic. So let's dive into the impact of hormones on the bladder. The first question they had was about hormonal changes during the perimenopausal and menopausal period, and how these changes might contribute to bladder issues like urgency or leaking.

And this is really such a great question. The female pelvis is full of estrogen receptors, and when there isn't estrogen in the pelvis, these receptors and the function of the pelvis is really different than it was before. This becomes really clear when you talk to patients about their leaking. One of the really common things that I hear from women is that their leaking is always worse before they start their period.

And this is because this is a time when there is a significant decrease in hormones and in estrogen. So we see more pelvic symptoms at that time when estrogen levels are low, even in young women. It doesn't have to be in the perimenopausal or menopausal period. So there are certain times where estrogen is low.

There are times in your cycle, like before your period. Estrogen is also low when you're breastfeeding. And there are certain types of hormonal contraceptive that can lead to low estrogen. And all of these times. Are times when women might be experiencing more bladder or even pelvic floor symptoms in general.

Perimenopause is a time when your hormones are erratic, so sometimes really high, sometimes really low. They don't follow the careful sequence that they followed when you were younger and more regular. Well, at least for most women, menopause is a time when estrogen is low, and it's really common for women to develop worsening urinary incontinence during the perimenopausal and menopausal periods because of the decrease in estrogen.

This is also a time where there can be shifts in weight. You can develop more central weight. That can be worse for leaking. It's also a time where you might be starting to have more muscle wasting or muscle atrophy. That starts when we're in our thirties, but in your fifties, you might be noticing the effects of that, and all of those things can impact your bladder function.

When I see someone in the office and they tell me they've had leaking for a long time and it's getting worse and it correlates. With their menopausal symptoms or with more irregular irregularity in their cycles. I'll often try vaginal estrogen, assuming that this is because the estrogen levels are low.

This won't cure the incontinence, but it can reverse things to the way they were before. All of the hormonal changes, and for some women, that's what they're looking for. They just kind of wanna return to that baseline that they were familiar with. They're not looking for a cure. And sometimes the estrogen may not be the whole answer, but it may be part of the solution.

Estrogen is such an important hormone in the female body. It impacts how our tissues work. It impacts how your sphincter close. It impacts how our collagen is synthesized. It impacts how fluid is processed in the body. It impacts how we can store fat, and all of this can impact urinary incontinence.

There've been a lot of studies about estrogen and urinary incontinence, but there have not been a lot of studies on progesterone and testosterone, and so these hormones probably impact the urinary incontinence mechanism as well, but we just don't know enough about it yet to really comment clearly on.

So the next question that I got asked was, are certain women at more risk for developing incontinence? And so what they were really looking at here is there some genetic variants, some genetic syndrome that makes you more likely to leak? So I will frequently see women who are members of families where all the women leak.

There's definitely a genetic component. We think that is because some people have collagen that is weaker, but. We don't really know what genes put you at more risk. So there have been studies done that have strengthened the hypothesis about genetic variants playing a role in the pathophysiology of urinary incontinence.

But we haven't been able to figure out what the exact genes are at that point. But that is ongoing research. I think. The other important thing to think about are the risk factors that put you at risk for urinary incontinence. So leaking is more common as we age. The common risk factors that we think about are.

Pregnancy. Pregnancy. Just being pregnant, not even delivering is a risk factor for urinary incontinence. Vaginal birth is a risk factor and women who have cesarean sections have less leaking, but they absolutely can have leaking as well from the pregnancy. An increase in weight, especially central weight, can lead to more leaking.

Women who have had a hysterectomy are more likely to leak. And then if you have more medical problems, you're more likely to leak. Women that are constipated are more likely to have bladder issues, and then smoking is a big risk factor that worsens bladder leaking. The system that keeps us dry is a really delicate one.

A lot of the factors above can weaken or damage the pelvic floor, which leads to increased leaking over time. Like I said before, our muscles waste or atrophy as we age. And so it's really important to actively strengthen these muscles as a source of prevention. So some things that you can do to prevent urinary incontinence, doing pelvic floor strengthening and starting before you're pregnant or during the first pregnancy.

Don't smoke. Maintain a healthy weight, and this is a hard one, but it definitely helps with incontinence. Maintain a strong core, avoid constipation. Those are the big things that you can do to help prevent leaking. So the next question was, what about non-hormonal factors like weight gain, like sleep, like stress?

Can these factors make leaking worse? And I would tell you weight gain, sleep and stress are three big factors that can impact everything in our. Body systems. Weight gain can definitely worsen incontinence, especially stress urinary incontinence. But the benefit of this is that weight loss can also make incontinence improve or even go away and weight gain, especially if you're someone who gains weight around your middle, that's a lot more pressure on your bladder.

And that is the type of weight that is really associated with worsening leakage. Chronic stress, acute stress, and poor sleep. These are all factors that impact different levels of hormones in her body. So when you have chronic stress, it increases your cortisol levels. When your cortisol levels go up and bear with me here for a minute, your antidiuretic hormones go up and this particular hormone makes you.

Urinate more. It makes you release fluid, and so if you're chronically stressed, you're someone who's gonna have more frequency, you might have more urgency, you might even have associated leaking. If you're someone who's having acute stress or short-term stress, that increases your adrenaline levels and that too can increase urination.

Okay. And in general, when you're tired, your body doesn't work as well. Poor sleep also impacts hormonal function. It changes your cortisol levels. It can even change reproductive hormones, and so there can be a physiologic reason why you might be having more urgency or more leaking with poor sleep. So the next question that they asked me is, how should women track or talk about these symptoms with their doctors, especially if they're embarrassed or unsure?

And I think this is such an important question. I don't think anyone should be embarrassed about leaking. It impacts nearly 25 million Americans. So many women leak. It's really a system failure. It is part of your body that is not working well. It really isn't any different than having hypothyroidism or a low thyroid.

It's not any different than having high blood pressure. It really is just an abnormality in one of your systems. But. I can talk about this all day. I can tell you not to be embarrassed or not to be nervous but that's really not the reality. There's a lot of shame that's associated with leaking.

People really don't like to talk about it. They get more nervous, I think if their physician's a male, even though that should not. Impact things. Male and female physicians hear about this all the time. I think it's easier for women to talk about their leaking, especially in an initial appointment in a virtual visit where they're not actually in the room and they're in their own environment and they feel a little bit more protected.

So you could consider. A virtual visit, but I think the most important thing to do would be to send a note to your physician about your sys symptoms and concerns before your appointment. So you could send that in through MyChart or through your portal. I think everybody has a portal these days. And then when you get to your appointment, you're gonna tell the assistant or the nurse, whoever's rooming you.

You sent a note with your concerns, and that's really what you're there to address and to review. And when the physician comes into the room, if they don't bring it up, then you wanna say that again because everything that you're worried about is written down and that will make it easier for you to communicate.

Hopefully they've already read it and they come in and they're prepared to talk to you about this issue. If they minimize your symptoms, you can say that these issues are important and bothersome to you, and you can ask for a referral to someone who might be more comfortable addressing them. You could even ask to see a urogynecologist or a pelvic floor physical therapist, but I think writing it down first.

So that you don't have to actually be the one to initiate the conversation or, you know, say the words that you don't wanna say. I think that just makes it much easier from a physician standpoint. This also is super helpful for me because it tells me what you're worried about. It gives me time to prepare and.

Create a plan before you're even in the office. So that would be my big tip, is to write it down, get it to your provider before you're even there. And then you know, once it's there, you're pretty much committed to talking about it and you can't back out even if you want. So the next question is. Why might hormone therapy not improve bladder symptoms in some women or even worsen them?

So this is something that we talk about a lot. And I would tell you that the reason for this is vaginal estrogen. So estrogen that you put in the vagina will help with bladder leaking, but systemic estrogen, so estrogen that you take by patch or by mouth does not, and systemic estrogen. So that oral and patch has actually been shown to increase the risk of leaking.

As has estrogen with different types of progesterone, so this isn't something that we really understand. But there have been multiple trials that have shown this. So the HERS trial, which is the heart and estrogen progesterone replacement study, the nurses' health study, the Women's Health Initiative, all of these studies have shown that oral estrogen or systemic estrogen, worse urinary incontinence.

And a lot of these studies compared the hormone replacement to placebo, so to taking nothing. And they found that it actually did worsen it. So that definitely happens. If I have someone who has bladder issues, I do not give them estrogen by mouth. I give them estrogen in the vagina. It really concentrates the amount of estrogen in the vagina and if there's someone who is on systemic estrogen.

Sometimes I will give them vaginal estrogen as well, because they need more estrogen in that particular area. So I think this is a really important point, and it's something that is being actively researched. We're trying to figure out exactly what helps and what worsens things and why. But the important thing to remember is that vaginal estrogen helps and oral estrogen does not.

The only other reason why estrogen might not help would be. If low estrogen really isn't impacting things, so let's say you have stress incontinence. Let's say that your sphincter is really weak. We give you estrogen. Maybe that helps to tighten things a little bit, but it's just not enough for you to see a result.

So sometimes it's not that the estrogen is making it worse, but it's just not helping in a way that will allow you to see improvement. The final question that I got asked was, a conclusion question, and that was, what do you wish more patients understood about the connection between estrogen and bladder control?

So I think we just need to understand our bodies a lot more, and I think it's important to know that your hormones can impact all kinds of things. And when your hormone levels are low or high, you're gonna get symptoms that you've never really thought about or have been educated about before. Ore, I see a lot of women who come in with bladder irritation and they think it's due to an infection.

But it is not because of the bacteria. So when I say this, it doesn't mean that you don't have symptoms. You absolutely do have bothersome symptoms, and it absolutely does feel like an infection, but. Those symptoms aren't being caused by a bacteria, and one of the most common reasons for this is a lack of estrogen.

So this can happen in perimenopause. It can happen in menopause, it can happen while breastfeeding. It can happen because of hormonal contraception. And this is something that I wish was more. Something that was just better understood that estrogen levels when they're low can cause very irritating symptoms that feel like an infection but are not an infection.

So you can have symptoms of an infection and it is not an infection, it's because of something else. And that's something that most people don't think about. Urinary tract infections are common and so it's, you know, really normal to associate the symptoms with something that you've had before.

And then, the other thing is something I've said before, which is that, you know, with bladder leaking with pelvic floor issues, vaginal estrogen may not be the sole answer for women, but it is often part of the solution. And that's something that we need to start thinking about. It's something that we need to start talking about, and it's something that women need not be afraid of.

There is still a lot of fear about estrogen. Even vaginal estrogen and vaginal estrogen is the safest form of estrogen that we can give women if it is taken at the prescribed. Levels, then it really is a local treatment, meaning that it stays in the pelvis and it doesn't get into your whole system, and that is something that is really important to understand.

So these were the questions that I got asked. By Flow space, it always helps me when someone asks me a question about something that I talk about all the time, it just helps me put it into a different perspective, talk about things in a slightly different light. It helps me address things in the way that you are thinking about them and not necessarily the way that I'm thinking about them.

So I always like being asked questions. I hope this was helpful for you and you learned something today. If you have any questions, please send them to me and I can use them in future podcasts.