Urinary incontinence in menopause: are you ignoring the symptoms?

How to spot symptoms and manage urinary incontinence during perimenopause and menopause

Urinary incontinence and bladder problems affect around six million people in the UK
Risk factors include falling hormones in perimenopause and menopause, pregnancy and obesity
Advice on how to spot symptoms, plus management strategies

If you have noticed more urine leaks and accidents since you hit perimenopause and menopause, then you are not alone. Declining levels of hormones, especially oestradiol (oestrogen) and testosterone, can affect your continence, which is the ability to control your bladder and when you urinate. The impact can range from inconvenience to a devastating effect on quality of life.

‘Urinary incontinence can be a difficult thing to talk about,’ says Newson Clinic GP and Menopause Specialist Dr Clair Crockett. ‘But it is incredibly common, especially around perimenopause and menopause. It can be really upsetting and distressing and have a big impact on women’s lives, leading to lots of planning, worrying and anxiety.’

Here we look at what can lead to incontinence during perimenopause and menopause, signs to look out for and where to seek help.

What is urinary incontinence?

Urinary incontinence is when you unintentionally pass urine. There are a number of different types, and they can all occur in a range of severity, from small leaks to larger volumes. It is estimated that around six million people in the UK are affected with bladder and incontinence problems – so if you have symptoms, please know you are not alone.

What are the symptoms of urinary incontinence?

There are number of different types of incontinence – here we look at the most common.

Stress incontinence is when you leak urine when your bladder is put under extra pressure, and could happen when you laugh, sneeze, lift something heavy or exercise. While it is normally small amounts of urine that leak, it can be larger volumes, especially if your bladder is very full. This happens when the pressure inside your bladder is greater than the strength of your urethra (the tube which carries urine out of your body) to stay closed.

Urgency urinary incontinence is urine leakage after a sudden, compelling need to urinate that is difficult to delay while you find a toilet.

Mixed incontinence is when you have both symptoms of stress incontinence and urgency.

Overactive bladder (OAB) is defined as urgency that occurs with or without urgency urinary incontinence, which comes with the need to frequently wee, especially at night.

What can put me at higher risk of urinary incontinence?

Factors which stretch, injure or put extra pressure on the muscles in and around your bladder and pelvis all contribute to a higher risk, including:

ageing: as you get older your muscles can weaken – although this doesn’t mean you should accept it as a natural part of ageing – and this risk starts to increase around the time of perimenopause and menopause, as your hormone levels begin to drop
pregnancy and childbirth: if you’ve been pregnant, your risk of bladder incontinence increases, and it can increase more if you had a vaginal delivery
having a hysterectomy
cancer treatments in the pelvic area
prolapse: a common problem when some of the tissues from your pelvis slip down slightly and bulge into your vagina
family history of incontinence
Obesity, and smoking now or in the past, can increase the risk of having bladder weakness [1]

RELATED: Pelvic floor and hormones

How common is incontinence in women?

Research has suggested the issue is incredibly common. One study looking at women aged around 35 to 55 years of age found that 30% to 40% said they sometimes leak urine [1].

Around 70% of menopausal women have genitourinary syndrome of the menopause (GSM) – this covers a range of symptoms, including an increase in the need to urinate and the urgency to do so [2]. Many young women also experience these symptoms, which are often related to low hormones in the genitourinary system but are often not diagnosed as being associated with changing hormone levels

Why can urinary incontinence occur in perimenopause and menopause?

During perimenopause, your levels of oestradiol, progesterone and testosterone, which are produced in your ovaries and brain, as well as other organs and tissues, start to decline until they reduce further during menopause. The loss of these hormones, particularly oestradiol and testosterone, causes the muscles that help support your bladder, known as your pelvic floor, and the muscles that close your urethra to lose strength. This loss of strength and tone can diminish your bladder’s ability to securely carry urine, says Dr Clair.

At the same time, the loss of these hormones also can affect the epithelium, the cells that form the top covering of your bladder, your urethra and your vulva, making them more sensitive, thinner, less flexible and less robust. This extra sensitivity can increase overactive bladder symptoms and bring on strong feelings of urgently needing to urinate.

‘Often perimenopause and menopause can exacerbate a problem that was already there,’ says Dr Clair. ‘A lot of women struggle with continence after pregnancy, and then when their hormone levels start to decline in their 40s, it can start to worsen.’

Can HRT help urinary incontinence?

First of all, make an appointment with your GP or a clinician who specialises in hormones to get a proper diagnosis and treatment advice. ‘Make sure you seek help as soon as possible, as there are lots of things that can be done,’ says Dr Clair.

Replacing low hormones by taking HRT, often with testosterone and/or using vaginal hormonal preparations, can help restore strength and tone to your muscles and tissues in your pelvic area. Vaginal oestrogen, applied topically in low doses to your vagina, and HRT via skin patches, skin gels or tablets, can lead to significant improvements, says Dr Clair. Vaginal DHEA (also known as prasterone) pessaries, which convert into both oestrogen and testosterone, can also be beneficial [3]. Using vaginal hormones can increase the concentration of hormones in your urinary system and pelvic floor muscles.

You may benefit from having both vaginal hormones and systemic HRT, or may start with a single approach depending on your symptoms, personal preferences and medical history. Adding in testosterone, which has a role in the strength of your pelvic floor, and which also declines as you age, can help some women improve their continence [4].

What other treatments are available for urinary incontinence?

While HRT can have an impact on symptoms for many women, there are several lifestyle factors that can help reduce your leakages whether or not you use hormones.

Pelvic floor exercises can help, and seeing a specialist physiotherapist for personalised advice can also be beneficial
Moderate weight loss (5-10%) has been shown to significantly reduce urinary incontinence episodes in overweight women [5]
Reduce caffeine intake from drinks such as coffee, tea and some soft drinks, and avoid fizzy carbonated drinks, which can irritate your bladder and bring on feelings of urgency. Aim to be hydrated
Limit or avoid alcohol and spicy food as these can irritate your bladder
Avoid irritation of the delicate skin of your vulva and around your urethra. Perfumes, powders, soaps, deodorants, spermicides and many brands of lubricants often contain chemicals that can irritate and should be avoided [6]
Tight-fitting clothing and long-term use of sanitary pads or continence pads, which can seem part of solution, can worsen symptoms by rubbing your delicate skin
Treat and manage vaginal and vulval dryness as this can irritate your urethra. As well as vaginal hormones, vaginal moisturisers and lubricants, which are available over the counter, can help bring you relief. Avoid intimate washes or intimate products as these can dry out these delicate areas – use a simple emollient to wash with such as Cetraben or Hydromol.

‘It’s important to make lifestyle changes alongside exploring hormonal treatments to get the maximum relief from symptoms,’ says Dr Clair. ‘Receiving the right treatment can be a journey, there may need to be different preparations and types of hormones tried along with lifestyle changes to find the combination that works best for you.’

If non-surgical treatments for urinary incontinence are unsuccessful or unsuitable, surgery or other procedures may be recommended [7].

Resources

NHS: Urinary incontinence

References

1. Danforth K.N., Townsend M.K., Lifford K., Curhan G.C., Resnick N.M., Grodstein F. (2006). ‘Risk factors for urinary incontinence among middle-aged women’, American Journal of Obstetrics and Gynecology, 194(2), pp.339–45. doi.org/10.1016/j.ajog.2005.07.051

2. Nappi R.E., Kokot-Kierepa M. (2012), ‘Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey’ Climacteric 15 (1): 36-44. Doi: 10.3109/13697137.2011.647840

3. Collà Ruvolo C., Gabrielli O., Formisano C., Califano G., Manna P., Venturella R., Di Carlo C. (2022), ‘Prasterone in the treatment of mild to moderate urge incontinence: an observational study’, Menopause, 29(8) pp957-962. doi: 10.1097/GME.0000000000002007. PMID: 35881944.

4. Kim, M.M., Kreydin, E.I. (2018), ‘The Association of Serum Testosterone Levels and Urinary Incontinence in Women’, The Journal of Urology, 199(2), pp522-27. doi.org/10.1016/j.juro.2017.08.093

5. Wing R.R., Creasman J.M., West D.S., Richter H.E., Myers D., Burgio K.L., Franklin F., Gorin A.A., Vittinghoff E., Macer J., Kusek J.W., Subak L.L. (2010), ‘Program to Reduce Incontinence by Diet and Exercise (PRIDE). Improving urinary incontinence in overweight and obese women through modest weight loss’, Obstet Gynecol, 116(2 Pt 1):284-292. doi: 10.1097/AOG.0b013e3181e8fb60

6. British Society for Sexual Medicine (2023), ‘Position Statement for Management of Genitourinary Sydrome of the Menopause (GSM)

7. NHS.uk (2022), ‘Surgery and procedures – Urinary incontinence’