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Urogenital problems

Introduction

After the menopause many women may experience urogenital problems such as vaginal discomfort and urinary incontinence.

The information below will help to explain some of these problems. The information is from After the Menopause, a personal guide for women, written by Dr. Annie Evans, Women's Health Specialist Bristol Royal Infirmary and Nuffield Hospitals.

Vaginal Atrophy: vaginal dryness, soreness and painful sex

Without the production of oestrogen by the ovaries, the skin and support tissues of the vulva ("lips") and vagina become thin and less elastic. This is an inevitable consequence of the menopause and the majority of women will experience some form of symptoms. Vaginal dryness is commonly the first reported symptom. This is due to a reduction in the production of mucus by the glands of the vagina.

Thinning of the vaginal and vulval skin can follow, which in turn makes them more easily damaged. This damage can occur more so during sex, especially if lubrication is also poor and even quite gentle friction can cause pain and discomfort. If the vulval lips are thin and dry, they can often rub on underwear causing soreness. Many women also dislike the outward changes in the appearance of the vulva (lips) as they lose their plumpness. It is not unusual that for many women, sex becomes difficult, painful, and of course unwelcome!

Alteration in the normal vaginal discharge is something noticed by most women after the menopause and also rarely discussed. Without oestrogen the pH (acidity) of the vaginal secretions changes and the normal discharge becomes more alkaline (like caustic soda!). This pH affects the balance of the micro-organisms in the natural secretions which in turn suppresses the normal levels of "good" bacteria (lactobacillus). The discharge changes in nature, becoming watery, discoloured and slightly smelly. This often leads to vaginal burning and vulval irritation.

Some seek advice from specialist clinics but most just worry and don't ask for help. Because of this relationships can sadly suffer and this is all completely unnecessary.

Management of vaginal atrophy

Some options that may help include:

These treatments are effective and acceptable and unlike the conventional form of HRT, the effects are local therefore the risk of systemic side effects are reduced.

Pelvic floor changes and prolapse

Many postmenopausal women become aware of ballooning or bulging of the walls inside the vagina, or even of a feeling of descent of the neck of the womb. Others simply experience a generalised pelvic dragging sensation. About half of post-menopausal women are found to have weakening of the front wall of the vagina (anterior vaginal wall prolapse); about a quarter have similar problems with the back (posterior) wall, and one-fifth with the highest part of the vagina.⁴

The muscles and ligaments of the pelvic floor (which should normally support the womb, bladder and other organs like a trampoline) are also oestrogen-sensitive, and changes in collagen, due to oestrogen deficiency, have a profound effect on the support mechanisms of the pelvic floor.

The protective covering of the clitoris is often affected by the changes in the collagen of the vulval skin, and the clitoris itself can become sore and traumatised. These skin changes are often so profound that genuine skin conditions emerge ("dermatoses"), and may need separate treatment.

Lower urinary tract symptoms

As they get older many women may find they have problems with their urinary tract ("water-works").

Some suffer from genuine stress incontinence, which is leaking of urine on coughing, sneezing or jumping, for instance. There is still a lot of debate about whether this is direct result of the loss of oestrogen after the menopause.

Urge incontinence is even less commonly referred, some postmenopausal women have difficulty "holding on" once they sense that they need to empty their bladder. They may also leak and start to pass urine before they can get to the toilet.

Other associated symptoms of the overactive bladder include frequency (recurrent need to pass urine) and nocturia (need to pass urine at night leading to recurrent wakening). Some women also feel they need to pass urine, having only just done so. All these may be connected to over activity of the muscle surrounding the bladder.

Recurrent urinary tract infections (UTIs)

This is another form of "waterworks" problem that affects women of all ages, but increases with age with many elderly women being particularly troubled.

Management of urinary problems

Local oestrogen

The role of local oestrogen in the management of urinary problems is complex. Oestrogen replacement therapy has been shown to alleviate urgency, urge incontinence, frequency, nocturia and dysuria (difficulty passing urine).6

Genuine Stress Incontinence would not appear to be helped by oestrogen alone, but it does seem to add to the action of other treatments currently used.

Pelvic floor exercises

Other strategies involve pelvic floor exercises. Many women have learnt these techniques for childbirth, but it is well worth revisiting them.

Pelvic-floor physiotherapists are the specialists in this field. They are able to fully assess a woman's pelvic floor function and teach appropriate techniques to strengthen it and train the bladder. They will then reassess and monitor improvements. They often use recording of pelvic floor muscle function, and various devices to help women perform appropriate exercises, such as weighted vaginal cones, or vaginal trainers. Often the practice nurse or GP can suggest referral to these practitioners.

Surgery

Sometimes assessment is needed using "urodynamics" in a specialist clinic, but only rarely is surgery needed. Modern surgical methods, however, are as non-invasive as possible, and very rarely is a hysterectomy needed.

If you would like to receive a full copy of the booklet After the Menopause please call Novo Nordisk on 0845 600 5055 (calls are charged at local rates and may be monitored for training purposes) or email CustomerCare@novonordisk.com.

Jargon buster

Discussing difficult problems with a healthcare professional…

Top tips for discussing "embarrassing" problems with a healthcare professional include:

References

1. Bachmann GA, Nevadunsky NS Diagnosis and treatment of atrophic vaginitis. Am Fam Physician 2000;61:3090-6.

2. Iosif C, Bekassy Z. Prevalence of genitourinary symptoms in the late menopause. Acta Obstet Gynecol Scand 1984: 63: 257-60

3.Brewer S. Intimate Relations: Living and Loving in Late Life. May 2004

4. Versi E et al. Urogenital prolapse and atrophy at menopause: a prevalence study. Int. Urogynecol J Pelvic Floor Dysfunct 2001; 12:107-10

5. Eriksen PS, Rasmussen H. Low dose 17 beta-estradiol vaginal tablets in the treatment of atrophic vaginitis: a double-blind placebo controlled study. Eur J Obstet Gynecol Reprod Biol. 1992; 44(2): 137-44

6. Milson I, Molander U. Urogenital ageing. J Br Menopause Soc, 1998; 151-156

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