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Bladder Control
Menopause Oasis
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This is a topic that very little has been written about, despite the frequency with which it occurs in women during peri-menopause and after menopause.

Our bladder control issues can suddenly leap from moderate (or nonexistent) to severe with the onset of peri-menopause, and especially take women who have never experienced childbirth by surprise. In the peri-menopausal years, our estrogen level begins to decline and we begin to notice less bladder control. Many women in their 30s notice a lack of control, and it seems to be a growing problem with women today. Of course we have begun to see many women entering peri-menopause earlier now too. The reasons why women lose their urine more easily, or experience frequency of urination, are not completely understood. Time for us to talk about it!!

What is it all about?

What is known is that when hormones begin to change, the bladder's elasticity, tissue health, and sphincter control are significantly affected. Just like the tissue in the adjacent vagina, the walls of the bladder, the urethra (the tube leading out of the bladder), and the meatus (the external area where urine comes out) are highly estrogen dependent. The drop in estrogen that occurs in peri-menopause and menopause can lead to urethral and vaginal atrophy - or thinning of the tissue in both areas.

One of the changes that women go through in peri-menopause is that the urethra shrinks and gets shorter. Eventually, the tube that goes from your bladder to the outside of your body is too short to sustain the pressure of urine in the bladder, and it starts leaking out.

You can use a mirror to check yourself. The normal appearance of the urethral tissue is pink, plump and moist. With declining estrogen it may appear very pale or almost white. This means the opening to the bladder may be weaker and less able to maintain good bladder control, or less resilient to irritation or infection.

Anywhere from 30 - 70% of peri-menopausal and menopausal women experience some symptoms of urinary incontinence, or enuresis. This loss of bladder control takes three main forms:
  •  leaking urine randomly (“urinary incontinence”) 
  •  leaking urine on coughing or sneezing (“stress incontinence”) 
  •  urgently needing to empty your bladder (“urge incontinence”)

You should see your health care provider to rule out any structural abnormality, infection or other medical condition that may be causing your urinary problems. However, if your symptoms arise during peri-menopause or after weaning off HRT, you are probably just suffering one of the common consequences of declining estrogen.

Many times the medication of choice is prescription-strength estrogen treatment to the area. This relieves the problem by thickening the mucosal lining and revitalizing it, returning moisture and suppleness to the tissues.

Bladder control and menopause:

As if hot flashes and mood swings weren’t enough, women going through peri-menopause begin to experience more episodes of urinary incontinence. The decrease in estrogen initiates a thinning and weakening of the pelvic muscles and connective tissue - our pelvic 'house' begins to sag a bit. Peri-menopausal women are also more prone to bladder infection, chronic urinary tract infection (UTI) or cystitis. As the urethral muscle loses strength and elasticity due to loss of estrogen, pockets of bacteria can flourish. Taking an antibiotic - now there is a one-day massive dose! - is usually adequate, but in some cases inflammation takes hold and damages the lining of the bladder. This condition is called interstitial cystitis (IC). It is a growing concern in women’s health. It is an inflammatory condition that manifests with all the symptoms of a urinary tract infection even when no bacteria are present. It is believed that an estrogen imbalance is somehow implicated in the escalating rates of interstitial cystitis.

What is female urinary incontinence?

A sudden urge to go, leaking urine, and frequent urination are all forms of urinary incontinence, which is generally defined as a lack of bladder control. While there are many causes, the most basic is a gradual weakening of the pelvic nerves, organs and smooth muscles that are meant to work together to control urination.

The bladder itself is a sac that stores the urine produced by the kidneys. When it is full, pelvic nerves send a signal to the brain that you have to “go.” Your pelvic muscles, especially the sphincter of the urethra, clench, and “hold it” until you get to the bathroom. Once you’re there and safe, your brain tells the sphincter muscles to relax and your bladder empties.

Unbelievably, the muscle anatomy “down there” is still not well understood by modern medicine. We do know that it is an intricate and amazing arrangement of dozens of muscles which keeps things in and lets them out as necessary. Naturally, the female pelvic floor is much more complex than the male pelvic floor because women have babies.

Many changes occur in the course of a lifetime. Inner pelvic muscles stretch and atrophy; muscles lose their elasticity; and organs actually move around, often pressing on the bladder itself. Sometimes the bladder or urethra may become damaged or chronically inflamed and malfunction. Scar tissue from surgery, injuries or infections may disrupt the natural alignment of the organs in the pelvic area.

Types of bladder problems:

Stress urinary incontinence (SUI) comes from the weakening of the pelvic floor resulting in pressure (or stress) on an otherwise fully functioning bladder. One minute you’re laughing, sneezing or coughing, the next moment your underwear is wet. Most women have experienced some degree of stress incontinence at some point or another. Exercise (particularly jumping), orgasm, and even hearing running water can trigger it - often with greater regularity during peri-menopause or after menopause.

Urge incontinence (UI) or overactive bladder (OAB) is a sudden, uncontrollable need to go, even if you just went ten minutes ago. It’s a result of uncontrolled contractions of the bladder muscle caused by a disruption in communication between the bladder and the brain. This happens due to inflammation of the bladder lining, infection, injury, natural atrophy that comes with age, or other reasons. Waking up once to several times at night to pee, called nocturia, is a common OAB complaint, as is accidental wetting due to an unstoppable urge to void. Sometimes overactive bladder is the result of overflow incontinence (see below). Prescription medications for urge incontinence such as Sanctura or Detrol can be helpful for OAB, but they do not relieve symptoms of stress incontinence. They can also cause many side effects, including dry mouth, constipation, headache, blurred vision and dizziness, to name a few.

Overflow incontinence occurs when you can’t evacuate all the urine in your bladder because muscle tone is weak or you have a blockage. Symptoms of overflow incontinence include dribbling, urgency, hesitancy, straining, a weak urine stream or low urine production even though your bladder feels full. This is more common in men, but occurs in a significant number of women too.

Once you and your doctor have a better idea which type of urinary incontinence you are experiencing, you have a better chance of getting to the root cause and making a decision on the best form of treatment.

Some other things you can do about urinary dysfunction:

After your doctor has eliminated any medical conditions, you need to support your body’s ability to make and balance its hormones.

Nutritional support - including nutritional supplements (including essential fatty acids) to provide the nutrients your body needs to make sufficient estrogen.

Endocrine support - that should include at least initially a natural progesterone cream. This alone can work wonders, especially in the beginning. Soy or other dietary sources of phytoestrogens for long-term support are also recommended.

Estrogen vaginal cream – a prescription-strength estrogen treatment applied to the vaginal canal. This relieves the problem by helping to thicken the mucous membranes that line the vaginal canal and surrounding structures; thus revitalizing them and returning moisture and suppleness to the tissues.

Pelvic floor exercises - Kegel exercises to strengthen urethral muscles and enhance control. You can do them anywhere, anytime - and you should. To do a Kegel, imagine that you are trying to stop yourself from urinating. Practice both short and long Kegels. You can even do an anticipatory Kegel before you sneeze or cough and prevent leakage! A wonderful added benefit of Kegels is that the increased muscle tone can increase sexual pleasure in both sensation and orgasm. (Male partners are happier too!)

If Kegel exercises don’t seem to work well for you, you can try vaginal insertable cones or balls (available through your doctor, your local XXX store, or from an Internet Web site) to help you train your PC (pubococcygeal) muscle. Biofeedback practitioners use electronic monitors inside the vagina to help women learn how to identify and tone muscles related to the bladder. Both tools can be very effective.

Any kind of physical exercise that engages your core will help strengthen your pelvic muscles. Pilates and yoga in particular are great inner toners. Both focus on building a firm core or root. They also use deep breathing and mindful movement to reconnect the brain to the body.

Acupuncture is another method that has provided symptomic relief for some women. It helps tone muscle and increase blood flow to the bladder. It can boost the immune system, soothe inflammation, and restore balance to the hormones.

Nutrition is vital to restoring a healthy balance to your endocrine and immune system, which in turn is important for maintaining muscle tone and preventing infection. Eat a diet of whole foods with plenty of fruits, vegetables, protein and some whole grains to promote adequate nutrition and help level out your hormones. Be sure to take a robust multivitamin, multimineral formula to support your body. And try supplements with cranberry extract - just be sure they don’t have added sugar.

Drink plenty of water and herbal tea. Flushing your urinary tract regularly will help evacuate bacteria. Cranberry juice and extracts can help prevent urinary tract infections by changing the pH of the bladder, but be sure you choose one with no added sugar. The more concentrated the urine, the more it will irritate the bladder. Eliminating caffeine, whether it's in the form of coffee, tea, cola, carbonated beverages, chocolate, or a medication that contains caffeine, will help too. Caffeine in the system can cause the bladder to spasm, causing urine leakage. If you are getting up in the middle of the night to urinate, stop drinking a few hours before bed.

Establish a better-bladder-control program. If you are urinating every one to two hours, try to wait longer - up to five to ten minutes longer each week -- between trips to the bathroom. If done properly, this will help you gain more bladder control and produce greater elasticity.

Allergies may exacerbate an overactive bladder. If you think you may have food allergies or sensitivities, try an elimination diet (avoiding a suspicious food for two weeks, then re-introducing it for a day or two).

While this does not completely address all of the issues concerning bladder control, it should give you some ideas as to what happens at this time of our lives to cause it. It should also, I hope, ease your concerns about being all alone with the problem! This is truly one of those un-mentionable symptoms of peri-menopause ~ and it shouldn't be! Talk with your doctor openly about it.  There is help to be found!