It wasn’t only the hot flushes and night sweats that were waking me up night after night. It was needing to pee as well. I know that this affects many of you too – because pre-pandemic, when I was travelling throughout New Zealand, Australia and the United Kingdom, sharing my Masterclass on Menopause with you, I saw hundreds of hands shoot up in the air and surprised faces, when I asked who was waking up because they needed to pee in the night. Perhaps this is you as well. Nobody told us that, yes indeed, this is a known symptom of our changing oestrogen levels as we move through menopause. But a word of caution – it can also be a sign of Urinary Tract Infection (UTI) too, so if you are experiencing any burning pain on urinating or if you have any pelvic or back pain, then head to your Doctor right away.
It’s such a challenge for many of us, especially those of us who aspire to continue to jog or run as we age. It’s no fun having to find a loo in the middle of a run nor in the middle of the night.
The Mystery of your Ageing Bladder in Menopause:
You may not know that you have an abundance of oestrogen receptors in your bladder and urethra. But many Urologists know this, because I bet they get to see a lot of middle-age women who are in menopause, presenting with bladder and pelvic floor problems. This includes stress incontinence and complaining that they are experiencing increased frequency and urgency in needing to pee. Epidemiologic studies indicate that approximately 1 in 4 women are affected by pelvic floor and urinary tract disorders with the highest rates in menopausal women. [Wu, Vaughan et al, 2014].
“There is clear evidence that oestrogen regulates the uro-genital tract. The abundance of estrogen receptors (ERs) in the urogenital tract explains why the natural reduction of endogenous oestrogen, the hallmark of menopause, can cause or potentiate Pelvic Floor Disorders (PFDs) and Urinary Tract Infections (UTIs).” [Alperin, Burnett et al. 2019].
Oestrogen is known to have an important role in the function of the lower urinary tract throughout our life. Oestrogen and progesterone receptors demonstrate an influence in the vagina, urethra, bladder and pelvic floor musculature and like most of our organs, when we go into peri-menopause (the start of menopause) and move towards post-menopause, our renal system is experiencing the result of declining oestrogen levels.
Positioning menopause in the women’s health and ageing studies helped me to understand better, the pelvic floor and urinary tract conditions that beset many of us in mid-life. Whilst it always pays to see a practitioner who specialises in this area, it also helps to understand what is going on and how we can help ourselves too. So, first things first. Your bladder and urinary tract is ageing.
As we move through menopause and lose the role of oestrogen attaching to the numerous receptors that infiltrate the pelvic floor walls, bladder, uterus and the muscles that hold organs in place, then, like many other organs, changes are occurring related to ageing. Age-related reduction in bladder capacity, reduced urine flow, diminished urethral pressure and the inability of your bladder to empty fully after voiding are known changes that occur as we age. But the thing that can upset many mid-life women the most, is the feeling of urgency. And this is all to do with the changes that occur to the nerves that infiltrate your bladder wall.
Your bladder is responsive to your stress hormones, adrenaline (epinephrine) and nor-adrenaline (nor-epinephrine). This is because the sympathetic nervous system exerts influences on the urethra and bladder for urine collection and storage. Your urethra and bladder are replete with adrenergic receptors. These receptors respond to your stress hormones, adrenaline and nor-adrenaline.
As we move into menopause and oestrogen levels decline, there is an effect on the response of the adreno-receptors in the urinary tract. Yes, they can get out of balance too resulting in an overactive bladder. This is more commonly known as ‘overactive bladder syndrome’ (OAB) or detrusor overactivity. The term ‘detrusor’ refers to the involuntary contractions during the filling phase of the bladder that may be spontaneous or provoked and is associated with urgency. This is why the most common symptoms of OAB are urgency, nocturia (night-time urgency), frequency and urge incontinence.
As our bladder fills up and stretches, there are changes to the nerve signals in the bladder wall and this can cause irritability and/or urgency and incontinence. All effects which can impact on our home, working and recreational lives. I know this has occurred for many MyMT women as it did for me as well. Night after night of getting up to have a pee is devastating for our energy. But researchers suggest that women with OAB have greater physiologic and psychologic stress reactivity than healthy controls. Importantly for women experiencing OAB, stress appears to exacerbate bladder urgency.
When you are experiencing higher levels of stress or you aren’t sleeping well, then your chronic stress hormone called cortisol, typically increases as does your blood pressure and heart rate. Inflammation increases as well and I’ve written about this numerous times in my newsletters. When cortisol is high, and there is a subsequent increase in your heart rate and blood pressure, this affects your bladder and urethra as well. Your bladder is under the control of the nervous system and is full of receptors that respond to stress hormones. At night when we don’t sleep well, cortisol levels remain high, as does your blood pressure and this affects the nervous system regulation of your bladder. It’s no surprise that we feel the urge to go more frequently, especially at night. Research suggests that this affects up to 80% of women in menopause (Alperin, Burnett et al, 2019). But as I mentioned earlier, this could be a result of UTI or pelvic floor disorder, so get it checked out because there are also medications which your Doctor can discuss with you.
What can I do about it? Here are my 5 pointers to help you:
- Re-address stress. Knowing that cortisol impacts your nervous system, especially your fight or flight nerves, and that your menopause changes impact on your nervous system, it pays to reflect on your stress levels. It is well known that anxiety increases in menopause, but again, this is also related to our changing oestrogen levels and the effect they exert on the nervous system, causing greater irritability of your nerves, including the nerves that sit within your bladder and urethra.
- Re-train your over-active nerves through relaxation exercises. This is hard to do, especially if you are experiencing urgency, but if your urgency isn’t to do with any bladder infection, then start to re-train it. When you feel the ‘urge’, then try to over-ride it with relaxation strategies and regular breathing through your nose. This will calm down your ‘fight or flight’ sympathetic nervous system. It may take a bit of time to do this, but as I say to women on the MyMT programmes, “your brain controls everything and in menopause, it just needs some re-programming now and again.”
3. Don’t forget your Kegel Exercises to Strengthen your Pelvic Floor. There’s so much going on in our lives and it’s easy to forget that menopause is a time to seek professional support with your pelvic floor. Kegel exercises, which involve squeezing and releasing your pelvic floor muscles in a timely manner, will assist in re-training the muscles that help to hold your pelvic floor in place. These muscles also lose the role of oestrogen and their loss of elasticity can cause some prolapse of your uterus or back pain from your shifting pelvis. I have Kegel exercises in my Rebuild My Fitness programme, but for those of you who can’t make it onto the programmes, then do get professional advice on the correct technique for these.
4. Practice emptying your bladder completely. The knowledge that our bladder undergoes changes in the bladder wall which affects its contractility means that when we do go to the loo, there tends to be some residual urine left in there. This can also make us more prone to UTIs, so practice emptying your bladder completely on urination.
5. Follow an anti-inflammatory diet. On the MyMT™ programmes, I show clear evidence as to the importance of following an anti-inflammatory diet during our menopause transition. As such I have modified the Mediterranean Diet to better suit our age and stage of life. Ageing (and therefore, our menopause transition) is known to cause increased inflammation in the body. This accelerates if you are eating the wrong food, if you are doing lots of exercise, if you are overweight or obese, and if you aren’t sleeping. All of these factors contributing to worsening inflammation in our body. Hence, one of the strategies to reduce cortisol levels (apart from re-learning how to sleep all night which I focus you on in the programmes) is to follow an anti-inflammatory diet. This will help reduce the inflammation that can cause bladder disruption and over-activity as well.
One of the most important things we can do is to ‘do something’! Like many of our symptoms in menopause, we become over-whelmed and don’t really associate the changes that we are experiencing with our menopause transition. But doing nothing is no longer an option as it was perhaps for our mother’s generation. As I often say to women in their menopause and post-menopause years, “you are the solution, not the problem.”
So, if you’re struggling with OAB symptoms, then get it checked out from Specialists in your area, and then come on board with me into any of the MyMT™ programmes because the first thing you are going to learn is how to sleep all night without having to get up and pee! A simple fix may be all it takes to let you live without the fear of experiencing incontinence and always having to quickly find a loo.
Alperin, M., Burnett, L., Lukacz, E., & Brubaker, L. (2019). The mysteries of menopause and urogynecologic health: clinical and scientific gaps. Menopause (New York, N.Y.), 26(1), 103–111. https://doi.org/10.1097/GME.0000000000001209
Harvard Health (2013). Overcoming an overactive bladder. Harvard Health Publishing Online.
Siroky, M.B. (2004). The Aging Bladder. Reviews in Urology, 6(1), 53-57.
Wu, J., Vaughan, C., Goode, P., et al (2014). Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet. Gynecol. 123, 141 – 148. [PubMed: 24463674].