Urinary Incontinence During Perimenopause

When my patients mention their issues with urinary incontinence (if they bring it up at all), they use hushed tones. It’s one of those things no one wants to talk about. After years in practice, I started proactively asking my patients about their bladder function because it was clear to me that many of them were suffering in silence.

As with so many aspects of aging and menopause, if we don’t talk about it, we can’t fix it. Given just how common urinary incontinence is, there are almost certainly many of you who might benefit from a conversation with your doctor about your symptoms.

Take me to the bottom line

What is urinary incontinence?

Urinary incontinence is the unintentional loss of urine. There are two main types of urinary incontinence that affect women during perimenopause and beyond.

The first is stress incontinence. This is when you cough, sneeze, laugh hard, or run, and it causes you to accidentally pee a little. The increased pressure in your belly and pelvis caused by sneezing or laughing can be too much for the muscles that make up your pelvic floor. The bladder sags a bit, the urethra gets compressed, and the muscular sphincter that keeps the urine in your bladder can’t hold up under the pressure and allows some urine to leak out.

The second type of incontinence is called urge incontinence or overactive bladder. With urge incontinence, the muscle that pushes urine out of your bladder contracts involuntarily. You can feel the sudden need to pee and sometimes some urine will leak out.

Some women have only stress incontinence or urge incontinence, but many women will have some of both. A randomly contracting bladder muscle combined with a compromised muscle holding your bladder shut create the perfect setup for incontinence.

What causes urinary incontinence?

Men can get urinary incontinence, but women experience it in greater numbers and at younger ages than men do. There are two main times women will develop incontinence: during pregnancy and around perimenopause (which is what I’ll be focusing on in this article). Incontinence during pregnancy is because the expanding uterus presses on the bladder and puts extra stress on the muscles of the pelvic floor. During perimenopause, the loss of estrogen can lead to vulvovaginal atrophy. As a result, the vagina and uterus can sag downward, pulling on the urethra. The sagging uterus can also put pressure on the bladder.

How many women experience urinary incontinence depends on who you ask. Estimates are all over the map — anywhere from 10% to 60%. This is likely related to how the data is collected; women may not report symptoms unless they are explicitly asked about them. The RISE FOR HEALTH study, which surveyed 3,000 women across the country, found that 45% of women had some symptoms of stress incontinence in the past seven days and 10% reported having symptoms all the time.

Some women are at greater risk of developing symptoms than others. The risk of incontinence increases with age. Having obesity is also associated with increased incontinence, likely as a result of increased pressure on the belly and pelvis. Multiparity — having had multiple pregnancies — is a risk factor, but women who have never been pregnant can also suffer from urinary incontinence. Family history plays a role as well, especially when it comes to overactive bladder.

For a long time, women were told to cut out their morning coffee to stave off urinary incontinence. The data regarding caffeine is mixed, though — tea but not coffee has been shown to increase urinary incontinence, and drinking decaffeinated coffee is associated with a reduced risk for urinary incontinence. The jury is out on other substances that have been studied. Studies of alcohol, artificial sweeteners, and cigarette smoking have all yielded mixed results in the data. Some of this variability may be due to other factors that aren’t being measured.

How is urinary incontinence diagnosed?

Tracking your symptoms is a good first step. Stress incontinence in particular can often be diagnosed based on a patient’s description of their symptoms. Women can often report when they experience symptoms with certain activities, such as running or yelling.

Overactive bladder can sometimes be harder to identify, though certainly your symptoms can be helpful. If symptoms are relatively new, your doctor might check your urine to see if you have a urinary tract infection. In more challenging cases, doctors often refer patients to a urologist or urogynecologist. These specialists can do more involved testing to help distinguish which type of incontinence might be at play so the incontinence can be treated more effectively.

What treatments are available?

The first step in treating incontinence is to treat any underlying issues. Antibiotics for a UTI or managing vaginal atrophy with vaginal estrogen can significantly improve symptoms. Pelvic floor therapy to strengthen the muscles that suspend the bladder and uterus in the pelvis has also been shown to be effective. In a cohort of nearly 1,000 women, 21% cured their urinary incontinence with pelvic floor therapy, and another 50% saw significant improvement in their symptoms.

Vaginal pessaries have also been used to treat stress incontinence. These devices are fitted by a gynecologist and help keep the pelvic organs in their proper place. However, pessaries have not been shown to be more effective than pelvic floor therapy. Rather, they are typically used in women who are unable to participate in pelvic floor therapy for some reason or who have symptoms with very specific activities, such as running.

In some cases, medications can be effective in treating overactive bladder. And in severe cases of stress incontinence associated with prolapse of the uterus, bladder surgery may be the best option, especially if more conservative measures like pelvic floor therapy haven’t substantially improved symptoms.

Women feel self-conscious about their urinary incontinence, but as we age it is a very common problem. However, women are often reluctant to discuss their symptoms with their doctor. But it is important that you do so, because urinary incontinence is often treatable with a combination of pelvic floor therapy, medications, and other interventions.

The bottom line

Urinary incontinence is common. As women age, they are more likely to experience incontinence. Having multiple pregnancies, having obesity, and having a family history of incontinence also increase a woman’s risk for urinary incontinence.
There are two main types of incontinence: stress incontinence, which causes urine to leak when a woman sneezes, coughs, or runs; and urge incontinence, in which the bladder muscle contracts uncontrollably.
Treating contributing factors, such as vulvovaginal atrophy, and pelvic floor therapy are first-line treatments, but in some cases medications or even surgery may be recommended.