Did you know that the average age of experiencing symptoms associated with menopause is 47.5 years old? And the average age of reaching menopause is 51 years? Women spend almost half their lives in menopause, so a key to enjoying our golden years is learning to manage and even reverse unwanted symptoms. If you are dealing with symptoms such as urinary incontinence, mood swings, hot flashes, and more, you may be wondering – is this really all due to menopause?

The menopause-incontinence connection

Hot flashes, mood swings, and urinary incontinence are just a few of the many symptoms associated with the onset of menopause. If you are going through this, you are not alone.

First, let’s define menopause. According to the North American Menopause Society, menopause is defined as the “final menstrual period … usually confirmed when a woman has missed her periods for 12 consecutive months ... Menopause is associated with reduced functioning of the ovaries due to aging, resulting in lower levels of estrogen and other hormones. It marks the permanent end of fertility.”

The symptoms of menopause look different for each woman. Some women may experience many symptoms while some experience very few. Common symptoms include mood changes, hot flashes, vaginal dryness, and brain fog. Once your body adapts to your new hormone levels, some of these symptoms may improve or disappear.

So, what about urinary incontinence? Urinary incontinence is not directly caused by the hormonal changes associated with menopause. However, urinary incontinence does often appear or worsen during this time. Let’s get into why this happens.

The steep hormonal drops during menopause can cause thinning of the pelvic floor muscle tissues. When paired with common lifestyle changes associated with aging as well as common unresolved pelvic floor weakness or issues from the past (that you may or may not have known you had), urinary incontinence can be the result.

These factors that often lead to or exacerbate an array of physiological changes include:

• Constipation
• Decreased muscle mass (due to less exercise or activity)
• Unresolved issues from past injuries
• Pre-menopause muscle weakness or tightness
• Unresolved muscle tissue changes from past childbirths
• Decreased water intake
• Decreased levels of exercise

Some of these may come as a surprise to you. For example, you may try to decrease your water intake or exercise to try and avoid leaking. However, limiting water and exercise leads to constipation and worsens incontinence. A true vicious cycle! Keep reading for tips to break this cycle.

Genitourinary syndrome of menopause (GSM)

Before we discuss ways to get rid of your urinary incontinence once and for all during or after menopause, let’s talk about genitourinary syndrome of menopause.

Genitourinary syndrome of menopause (GSM) involves progressive changes to the vulva, vagina, and lower urinary tract system due to decreased estrogen levels. Common symptoms include vaginal dryness, reduced lubrication, and pain with vaginal penetration. Other symptoms include increased urinary urgency and frequency, urge and/or stress urinary incontinence, and recurrent urinary tract infections.

GSM is more common than you may think! In fact, 50-70% of postmenopausal women are symptomatic to some degree. If you are dealing with symptoms of GSM, consider using a lubricant during intercourse. Vaginal lubricants are designed to ease penetration. (Examples include Good Clean Love, UberLube, Intimate Rose, and Slippery Stuff.)

In contrast, a vulvar or vaginal moisturizer can be helpful to improve vulvar or vaginal moisture throughout the day, can last several days, and helps with chronic dryness. Since these moisturizers are absorbed into the skin, they don’t help with ease of penetration (that’s what your lubricant is for!). Consider a vulvar or vaginal moisturizer such as V-magic, Good Clean Love’s moisturizer, Ah Yes VM, Sliquid Satin, or Intimate Rose’s moisturizer. Check with your doctor before use or if you have any questions.

To help with the dryness and irritation of vulvar or vaginal tissue, some women benefit from hormone replacement therapy or topical estrogen cream. This bulks up vulvar or vaginal tissue, reduces discomfort, and improves the function of the pelvic floor muscles. Speak with your doctor about this option if you feel it would be appropriate for you.

A pelvic floor physical therapist is also a great resource to help you manage and improve your symptoms through hands-on treatments and exercise, either alone or as an adjunct to other treatments such as hormone replacement therapy. If you have questions about GSM or symptoms associated with menopause, chat with Flyte’s complimentary Ask A (Pelvic) Physical Therapist service today.

What else happens to my vagina during menopause?

Urinary incontinence associated with menopause can appear in a variety of forms: urge, frequency, stress, or mixed (both urge and stress incontinence). Stress urinary incontinence (SUI) is defined as urine leakage with sneezing, coughing, laughing, jumping, running, or other daily activities like moving from sitting to standing.

SUI may be caused by weak pelvic floor muscles. Weak pelvic floor muscles are unable to contract properly to close the urethral sphincter where urine escapes the body. When paired with the hormonal changes of menopause and the resulting changes in tissue flexibility or elasticity of the vulva, vagina, and urethral sphincter, urinary incontinence will appear or worsen.

Furthermore, discomfort in the vulva and vagina associated with menopause-related vaginal dryness or pain may lead your pelvic floor muscles to compensate and contribute to worsening urinary incontinence.

Charting your menopause symptoms

Are you asking yourself “What can I do to help deal with these annoying, inconvenient symptoms?”

Begin by cataloging your specific symptoms. Here is a checklist to help you:

Check	Symptom & Description
	Vulvar dryness: external itchiness or discomfort of your vulva
	Vaginal dryness: internal itchiness or discomfort or feeling of friction inside your vagina, with or without intercourse
	Urinary urge: a strong urge to urinate that hits suddenly
	Urinary frequency: emptying your bladder more than 9x in 24 hours
	Stress urinary incontinence: loss of urine with activities such as sneezing, coughing, laughing, running, jumping, getting up from a chair, etc.
	Urge urinary incontinence: loss of urine due to strong urinary urge, often while rushing to the toilet to empty your bladder
	Provoked vestibulodynia: stinging, burning, sharp, and/or raw pain in the vulvar region that occurs with when your vulva is touched, such as during vaginal intercourse
	Constipation: having a bowel movement less than 3x per week and/or needing to strain to pass bowel movements that are hard and small in consistency
	Nocturia: waking up from sleep during the night to urinate (usually >1 times per night)
	Hot flashes
	Night sweats
	Changes to your memory
	Brain fog
	Fatigue
	Weight gain

Once you have a better understanding of your symptoms, you can better advocate for yourself with your healthcare provider and discuss ways to better manage symptoms throughout your body’s transition into menopause. Remember, just because you are dealing with these symptoms now does not mean you have to deal with them forever!

Keeping a bladder diary

Next, consider keeping a bladder diary.

A bladder diary is a simple and easy way to track your urinary symptoms to better understand the potential causes of your leaks.

To fill out a bladder diary, fill in the columns with:

Type & Amount of Food & Fluid Intake	Note any time you eat or drink. Try accurately record amounts (i.e. 8 oz of water or 6 oz of red wine)
Amount Voided	Record the amount you urinate at one time. An easy way to do this is to count in seconds (1-Mississippi, 2-Mississippi, etc.) how long it takes you to urinate. Note if you have a slow or fast stream or any hesitancy starting your flow.
Amount of Leakage	Record S for small, M for medium, and L for a large amount of leakage. A good rule of thumb: Small = drops, Medium = underwear wet, Large = outerwear wet.
Was Urge Present?	Record 1 for a mild urge, 2 for a medium-strength urge, and 3 for a strong urge.
Leakage with Activity?	If you have leakage with a specific activity, log the activity in this column (ex: sneeze).
Pads & Other	Record any pad changes and any other information that you believe to be important.

Try to fill out 3 of these bladder diaries for different days that represent different schedules in your week (i.e., a workday, a weekend day).

Once you have several days of your diary, take some time to look through the data you collected to see if you can find patterns. Here are some things to look for:

Frequency of urination The typical number of times to urinate per day is between 5-9. Count the number of logged urinations under the “Amount Voided” column.  o   If fewer than 5 times: Are you in a job where it is hard to step away to use the bathroom? Are you nervous about drinking water to avoid leaking? Fewer than 5 voids per day can be a sign of dehydration. o   If greater than 9 times: Are you giving into every urge your bladder sends you? Are you emptying your bladder before you really need to? It might be time to work on urge suppression techniques (described below) to help control your bladder.

Length of urination We typically want to urinate for between 8 and 20 seconds. Review the “Amount Voided” column – are you going fewer than 8 seconds or more than 20 seconds? o   If fewer than 8 seconds: It’s likely you didn’t really have to urinate yet even though it felt like you did. This may be contributing to and increasing your urinary urgency, frequency, and incontinence. Your urine may be too concentrated (you are likely dehydrated) and is irritating your bladder, causing you to feel the urge to urinate. This may be a habit you’ve created over time by peeing “just in case” when you didn’t really need to go. This is a habit that can be fixed! TIP: Try some urge suppression techniques like 10 quick Kegel contractions, controlled diaphragmatic breathing, or stopping what you are doing, sitting down, and distracting yourself. You can also try heel raises or toe scrunches, sitting on your heels, and/or gently applying pressure on your perineum (the area between your anus and vulva) with your fingers. Once you have control, you can calmly walk to the bathroom with less risk of an accident. o   If greater than 20 seconds: Are you “holding it in” for long periods of time before heading to the toilet? If you are holding it for more than 4 hours, you are putting yourself at risk for bladder leaks. Normal bathroom breaks are every 2-4 hours.

Links to foods & drinks Take a look at the last two columns “Was Urge Present” and “Activity with Leakage”. Certain foods can irritate the bladder, creating a strong urge or increasing the chance of leakage. o   Patterns with foods? Maybe spicy foods, tomato sauces on pizza or pasta, acidic fruits? If so, try avoiding your trigger foods and reassess your symptoms. o   Patterns with drinks? Like foods, certain beverages can irritate the bladder. Familiarize yourself with common bladder irritants and see if you find connections between your beverage consumption and leaks.

These are some ways to begin reflecting on your bladder habits and the contributing factors to your urinary symptoms. Save your bladder diary and take it with you to your next doctor or physical therapy visit for additional help.

At-home tips for urinary incontinence  

Although you may be tempted to reduce your water intake because of your bladder leaks, dehydration will actually worsen your symptoms. Decreasing water intake causes your urine to become more concentrated and acidic. This can irritate the bladder lining and cause increased leakage.

Decreasing water intake can also lead to constipation. Constipation places additional pressure on your bladder and contributes to increased incontinence. When constipated, you may be straining to pass a bowel movement. This straining causes downward pressure in through your pelvic floor, leading to more pressure on your pelvic floor muscles and worsening urinary incontinence (and even leads to prolapse symptoms!). Research has found drinking 2.0 L/day (~68 oz) of water along with taking 25 grams of fiber, improves constipation symptoms because fiber retains water, making stool softer and easier to pass. 

So how do you know if you are drinking enough water? That will vary depending on your activity levels and your body. A good rule of thumb is to drink water when you feel thirsty and keep your urine clear. If your urine is dark yellow, time to up your water!

Sip your water slowly throughout the day instead of gulping it down. This helps your body better absorb water and stay hydrated for longer periods of time. If you are dealing with urinary incontinence and aiming to increase your water intake, aim to gradually increase the amount you drink by 1-2 oz per day to allow your bladder and body to adjust to the change.

If you are dealing with stress urinary incontinence (leakage with activities such as sneezing, coughing, laughing, jumping, etc.) try learning The Knack!

The Knack is a useful technique for women with bladder leaks. This technique not only helps with incontinence, but also with prolapse, controlling intra-abdominal pressure, and helps protect you after a hysterectomy.

The Knack is a well-timed pelvic floor contraction in which you:

1. Contract (squeeze and lift) your pelvic floor muscles prior to and during the sudden activity that causes urinary leakage.
2. Hold the squeeze.
3. Release your pelvic floor muscles when the activity is done.

When you are doing The Knack, you are helping to close the urethra where urine passes, to help control bladder leaks and manage intra-abdominal pressure. This is a useful technique to practice with a cough, sneeze, or a laugh - think to yourself, "Squeeze before you sneeze."

Trouble finding your pelvic floor muscles? Watch the video below for a quick Kegel how-to guide.

Did you know that your diaphragm is a muscle? It plays a starring role in breathing and is also one of the most important muscles making up your core. Breathing properly plays an important role in reducing pressure on your pelvic floor.

In “diaphragmatic breathing” (also called deep breathing, belly breathing, or 360-degree breathing) your “stomach, rather than your chest, moves with each breath, expanding while inhaling and contracting while exhaling”.

What does this feel like? When you use your diaphragm to inhale (breathe in), your belly will rise and expand. As this happens, your diaphragm contracts and moves down towards your feet and your pelvic floor relaxes, stretches, and also moves down or “lengthens” toward your feet. When you use your diaphragm to exhale (breathe out), your diaphragm moves back up toward your head and into its elevated resting position, and your pelvic floor also draws back up toward your head. This natural coordination helps manage intra-abdominal pressure and is essential to managing issues like urinary incontinence.

Practice diaphragmatic breathing throughout your day so that it eventually becomes your new way of breathing. Try not to force your belly to expand. Instead, focus on keeping your breath gentle and imagine an umbrella opening in your abdomen during your inhale and the umbrella closing during your exhale. Other helpful cues are to imagine you are sniffing freshly baked cookies in the oven or smelling pleasant roses on a spring day.

If you are leaking with activities such as running or jumping, focusing on diaphragmatic breathing throughout can be helpful. Additionally, if you feel the urge to urinate hit suddenly, practice your diaphragmatic breathing followed by the urge suppression techniques suggested above.

What else can I do to help my pelvic floor muscles?

Changes that occur with aging and menopause do not have to decrease your quality of life. There are many treatments, techniques, and solutions that can help manage, improve, and eliminate your symptoms. Pelvic floor muscle strengthening can be highly beneficial to stop or reduce urinary symptoms.

Flyte®, an FDA-cleared in-home intravaginal treatment for bladder leaks, uses the proven modality of mechanotherapy to treat bladder leaks by toning and strengthening your pelvic floor muscles. Flyte is fast - only 5 minutes a day for 6 weeks. Flyte’s mechanotherapy increases the impact of your Kegels by 39x. This means you will see results faster than doing Kegels alone.

In clinical study, 82.9% of women using Flyte achieved continence in just six weeks – and two years after using Flyte 77% of participants reported continued continence. Flyte has been proven effective for mild, moderate, and severe leakage. And 90% of customers say Flyte is easy to use!  If you have questions or are simply looking for guidance, Flyte’s provides support to all women with a complimentary Ask A (Pelvic) Physical Therapist service. Schedule a call with a pelvic floor physical therapist here.

               

Although menopause and its symptoms can feel overwhelming and cause disruptions in your quality of life, it’s crucial to remember you have the power to reclaim control and embrace this new phase of life with confidence. With multiple treatment options, including at-home self-care options, the right healthcare professionals, and a strong support system, you can navigate the menopause transition confidently. Menopause is not a setback, but a steppingstone to a vibrant next chapter of life.

 

Authors:

Shravya Kovela, PT, DPT, OCS

Leah Fulker, PT, DPT, PCES