Menopause occurs when a woman hasn’t menstruated in 12 consecutive months and can no longer become pregnant naturally.
It usually begins between the ages of 45 and 55, but can develop before or after this age range. Menopause can cause uncomfortable symptoms. An article in Healthline discussed that symptoms women experience are primarily related to a lowered production of the female sex hormones estroge and progesterone. Symptoms vary widely because of the many effects that these hormones have on the female body.
Estrogen regulates the menstrual cycle and affects the following parts of the body:
- reproductive system
- urinary tract
- blood vessels
- mucous membranes
- pelvic muscles
One symptom women may experience is overactive bladder. They may feel a constant need to urinate even without a full bladder, or experience painful urination. During this time tissues in the vagina and urethra lose their elasticity and the lining thins. The surrounding pelvic muscles may also weaken.
Previous studies have shown that the vaginal microbiome decreases in Lactobacillus predominance and becomes more diverse after menopause. It has also been shown that estrogen therapy restores Lactobacillus dominance in the vagina and that topical estrogen is associated with overactive bladder symptom improvement. We now know that the bladder contains a unique microbiome and that increased bladder microbiome diversity is associated with overactive bladder. However, there is no understanding of how quickly each pelvic floor microbiome responds to estrogen or if those changes are associated with symptom improvement.1
A recent study aimed to determine if estrogen treatment of postmenopausal women with overactive bladder decreases urobiome diversity. They analyzed data from postmenopausal participants in 2 trials who chose vaginal estrogen as the primary overactive bladder treatment and used 0.5 g of conjugated estrogen (Premarin cream; Pfizer, New York City, NY) twice weekly for 12 weeks. Baseline and 12-week follow-up data included the Overactive Bladder questionnaire, and participants provided urine samples via catheter, vaginal swabs, perineal swabs, and voided urine samples. Microbes were detected by an enhanced culture protocol. Linear mixed models were used to estimate microbiome changes over time. Urinary antimicrobial peptide activity was assessed by a bacterial growth inhibition assay and correlated with relative abundance of members of the urobiome.
In this study, 12 weeks of estrogen treatment resulted in decreased microbial diversity within the vagina (Shannon, P=.047; Richness, P=.043) but not in the other niches. A significant increase in Lactobacillus was detected in the bladder (P=.037) but not in the vagina (P=.33), perineum (P=.56), or voided urine (P=.28). The change in Lactobacillus levels in the bladder was associated with modest changes in urgency incontinence symptoms (P=.02). The relative abundance of the genus Corynebacterium correlated positively with urinary antimicrobial peptide activity after estrogen treatment.
Estrogen therapy may change the microbiome of different pelvic floor niches. The vagina begins to decrease in diversity, and the bladder experiences a significant increase in Lactobacillus levels; the latter is correlated with a modest improvement in the symptom severity subscale of the Overactive Bladder questionnaire.2
So what does this mean for patients postmenopausal women? We know that vaginal estrogen has many benefits. It is commonly used for symptoms such as:
- Vaginal dryness
- Vaginal itching
- Vaginal burning
- Pain during sex due to lack of natural vaginal lubrication
- Painful urination
- Difficulties urinating
- Sudden and frequent need to urinate
It can also decrease urinary tract infection rates and other urethral and bladder symptoms. In fact, some patients are treated repeatedly for UTIs or are diagnosed with Painful Bladder Syndrome or Interstitial Cystitis when they may actually have a local estrogen deficiency (vaginal /urethral). Since vaginal estrogen changes the microbiome it can help manage or prevent these issues.
Generally vaginal estrogen takes two to three months to start seeing a positive effect. Often women stop using it after a few weeks if they are not counseled to continue, as they think it is not working.
Also keep in mind that it comes in various forms. There are suppositories, applicators, pills, topical creams, vaginal inserts, and compounded creams. One patient may do well with one form, and another may not. They may need to figure out which works best for them.
As with any medication it is important to discuss benefits verses risks with your doctor, and be aware of any side-effects.
Some things to discuss with your doctor if they are persistent when using vaginal estrogen are:
- breast pain or tenderness
- difficulty falling asleep or staying asleep
- changes in sexual desire
- hair loss
- unwanted hair growth
- spotty darkening of the skin on the face
- sudden feelings of heat or sweating
- difficulty wearing contact lenses
- leg cramps
- swelling, redness, burning, itching, or irritation of the vagina
- vaginal discharge
- painful or difficult urination
- back pain
- cold symptoms
- flu symptoms
Some side effects can be serious. If you experience any of these symptoms, call your doctor immediately:
- bulging eyes
- pain, swelling, or tenderness in the stomach
- loss of appetite
- yellowing of the skin or eyes
- joint pain
- movements that are difficult to control
- rash or blisters
- swelling of the eyes, face, tongue, throat, hands, arms, feet, ankles, or lower legs
- difficulty breathing or swallowing3
Of course, there are other options to managing this issue during menopause. According to the National Association for Continence, the first line of treatments for OAB should be the most conservative. This includes:
- Physical Therapy: To address pelvic floor muscle issues that cause these symptoms.
- Bladder retraining: This may help with gradually building up the amount of time you can wait to go to the bathroom when you need to urinate. It can also help lower your risk for incontinence.
- Double voiding: Wait a few minutes after urinating and go again to make sure that your bladder is completely empty.
- Absorbent pads: Wearing liners may help with incontinence so that you don’t have to interrupt activities.
- Maintaining a healthy weight: Extra weight puts pressure on the bladder, so weight loss can help ease symptoms.4
Many women find that a combination of treatments is what is needed in order to overcome this issue.
- DOI: 10.1016/j.ajog.2020.08.006
- Thomas-White K, Taege S, Limeira R, Brincat C, Joyce C, Hilt EE, Mac-Daniel L, Radek KA, Brubaker L, Mueller ER, Wolfe AJ. Vaginal estrogen therapy is associated with increased Lactobacillus in the urine of postmenopausal women with overactive bladder symptoms. Am J Obstet Gynecol. 2020 Aug 11:S0002-9378(20)30834-6. doi: 10.1016/j.ajog.2020.08.006. Epub ahead of print. PMID: 32791124.