Ask an Expert: Menopause and Incontinence

Answer from Nancy H. Sullivan, CNM, MS:

You are describing stress incontinence, or sudden urine loss. It accounts for the majority of urinary incontinence in women. And yes, it is related to menopause.

Estrogen, the female hormone that plummets after menopause, helps keep the muscles that control the bladder strong. It also contributes to the health of the urinary tract lining.

In the past, many women took hormone replacement therapy (HRT), a combination of estrogen and progestin, to deal with many of the effects of menopause. But in July 2002, a large clinical trial, the Women's Health Initiative, released some findings that dramatically lessened the long-term use of HRT because the hormones increased the risk of invasive breast cancer, coronary heart disease, stroke and pulmonary embolism. Urinary incontinence, as you may know, is the medical term for leaking urine. It may be common, but no one has to suffer through it. You can definitely take steps now to minimize the problem: exercises to strengthen the pelvic floor muscles.

You might think your bladder would be fine if only you could safely take HRT. But, oddly enough, another research study, using data from the Nurses Health Study participants, showed that HRT appeared to increase the risk of developing urinary incontinence whether the hormones were taken by pill or absorbed through the skin. An Australian study of older women had similar findings.

Embarrassed? Don't be
And while you may consider it incredibly embarrassing to be in this situation, please be reassured that you have much company, and that health professionals are very accustomed to dealing with it. Forty percent of post-menopausal women have some sort of problem with urinary incontinence. That's a huge number of women. Most of them simply use sanitary pads. That's too bad, because there are much better solutions.

Those solutions include exercises to strengthen the pelvic floor muscles, physical therapy, collagen injections around the urethra, insertable devices, and minor or major surgery.

Also, you should make sure another situation isn't aggravating the lack of estrogen. Bladder infections, constipation, medications, abnormalities with your urinary tract, some foods and beverages (e.g., caffeine, alcohol, citrus juice, spicy foods, natural and artificial sweeteners) and neurological disorders are among the things that can also affect bladder function.

Understanding the pelvic floor
As you've noticed, in stress incontinence, you leak a small amount of urine when there's a sudden increase of abdominal pressure on the bladder. That pressure can be caused by laughing, coughing, sneezing, high-impact exercising, rising from a low chair or awkwardly lifting a heavy object.

The reassuring news: Pelvic floor exercises will likely help you minimize or completely avoid the problem.

The pelvic floor muscles are a hammock supporting the organs of the pelvis including the bladder. These muscles also surround the openings of the vagina, anus and urethra. (The urethra is the pipe that carries urine from your bladder out of your body.)

When the muscles that control the junction of the bladder and urethra do not work properly, urine can suddenly leak out because the urethra doesn't stay tightly closed.

In addition to a lack of estrogen, excess weight can weaken the bladder and the muscles supporting it. If you're over your ideal weight, urinary incontinence is yet another reason to achieve and maintain a healthy weight.

One, two, three, squeeze!
Pelvic floor exercises are also called Kegels. If you were ever pregnant, you may have done these during pregnancy. To perform Kegels correctly, you must first figure out the proper set of muscles to tighten. The pelvic floor muscles are the ones that allow you to "hold it" when you have the urge to pass gas or urinate at an inappropriate time. They include the vaginal muscles that get a workout during sex. 

You can find Kegel instructions and diagrams on the American Physical Therapy Association (APTA) Web site.

To begin, lie on the floor and squeeze or pull in the pelvic muscles. Keep them tight for a count of three. Release; rest for a few seconds. Repeat. (Remember to keep breathing!)

The goal, over time, is to work your way to 10-15 repetitions per set. Vary the routine a bit. Do Kegels while sitting down or standing, not just lying down. I like the APTA recommendation to sometimes tighten the muscles for five to 10 seconds, and other times to quickly contract and release. This makes the exercises much more effective.

Some Kegels here, some Kegels there
As you master Kegels, you can practice them at odd moments: in line at the store, waiting for an appointment, riding the bus, on-hold on the phone. No one will be the wiser. Challenge yourself by coughing or clearing your throat while performing Kegels.

We advise doing a set of 10-15 Kegels at least three times a day. As the muscles build strength, your bladder control will improve. The length of time depends on the woman; it can be anywhere from three weeks to 12 weeks. Once you succeed, don't slack off. Continue as many sets of Kegels a day as needed to keep the problem under control.

Still having a hard time?
Studies show that about one of every three women has a hard time isolating the pelvic floor muscles on her own. Do ask for a referral to a physical therapist specializing in women's issues if you need help. Physical therapists use a biofeedback device or electrical stimulation to teach you to isolate and work the right muscles. They are very experienced in this matter.

If your leaking episodes persist, absolutely let your health care provider know so you can explore other causes and solutions.