What are genitourinary syndrome (GSM), urinary incontinence (urinary leakage) and vaginal atrophy (dry vagina)?
Genitourinary syndrome (GSM) is a relatively new term that covers a variety of changes to the genitourinary tract – particularly the urethra and vagina. This is the result of changing hormone levels during the menopausal transition. Urinary incontinence (UI) and vaginal atrophy are the most common symptoms of GSM, affecting 40-50% of midlife and aging women.
Urinary stress incontinence (stress UI) is the loss of urine when coughing, sneezing, laughing, jumping on a trampoline or lifting heavy objects. UI and recurrent urinary tract infections (UTIs) can occur during perimenopause and post-menopause when the muscles that keep the urethra closed weaken due to decreasing estrogen or lack of exercise. The estrogen-dependent lining of the outer urethra empties the bladder, and as the lining thins, the urethra may become weaker than the pressure in the bladder. This imbalance leads to involuntary loss of urine. Stress UI also occurs when the pelvic floor is weakened, damaged or as a complication of obesity.
“Urge” urine leakage (urge UI) happens when muscles in the bladder’s walls don’t work well. It feels like an urgent need to pee. Urge UI can result from drinking too much caffeine or alcohol, from diminished estrogen during perimenopause or as a complication of obesity.
In vaginal atrophy, the vaginal walls can become weak due to decreasing levels of estrogen. The change in estrogen may also cause the slippery lining of the vagina to become dry and thin.
Women may be very reluctant to speak up and act on UI and vaginal issues due to embarrassment and negative feelings about aging. However, these are conditions that can be treated at home or with the help of a medical practitioner.
Self-care for urinary incontinence
You can take significant steps to treat incontinence on your own with some straightforward lifestyle changes.
- Strengthen your pelvic floor muscles through Kegel exercises. Make sure your Kegel exercises are done correctly as they can otherwise cause some harm. Talk to your medical care provider or find a physiotherapy that specializes in pelvic floor exercises.
- Try bladder training through a combination of scheduled bathroom visits and delayed urination
- Keep a journal to identify and monitor triggers
- Reduce intake of caffeine and diuretics to minimize excess urine production
- Find the right balance of fluid intake. Drinking too much or too little can make incontinence much worse.
- Empty your bladder before bedtime to promote an uninterrupted night of sleep
- For added peace of mind when out in public, use pantiliners or pads for extra protection. There are also now many brands of comfortable but absorbent protective underwear.
Self-care for vaginal atrophy
To address vaginal atrophy at home, you can:
- Use over-the-counter lubricants to hydrate the walls of your vagina. This can also help reduce vaginal infections.
- Stimulate the muscles of the vaginal wall with vaginal sex and masturbation.
- Avoiding vaginal intercourse when experiencing pain and dryness, as this can result in tearing delicate tissues and may lead to infections
- Seek medical care if self-care doesn’t help.
Therapy for vaginal dryness and urinary incontinence
At age 40 find a reliable, educated primary care provider familiar with recognizing and treating the symptoms of perimenopause and menopause.
Topically (locally) applied hormone therapy (HT) with estrogen is safe and often effective for reducing dryness in the vaginal lining and improving strength of the vaginal wall. It also improves the strength of the urinary bladder sphincter muscles and helps with stress incontinence.
Topical HT comes in the form of creams to apply inside the vagina or tablets and rings that can be placed inside the vagina. Locally applied estrogen can also help to reduce the incidence of urinary tract infection.
Healthy weight loss is also effective at decreasing urine leakage.
Kegel exercises, alone or combined with therapy, are very effective at strengthening the pelvic floor muscles. Physiotherapists can provide Kegel exercise training.
Physicians may also prescribe a pessary. This ring is inserted into the vagina to push against the vaginal wall and nearby urethra. The pressure helps to reposition the urethra and reduce leakage. It is recommended when the incontinence is a result of a pelvic organ prolapse, where the uterus and/or bladder bulge into the vagina.
How a healthy vagina works
Vaginas are part of a woman’s sexuality and reproduction and can be healthy throughout life.
The walls of a vagina are muscular, and with stimulation and estrogen support, can remain strong and thick. The vaginal lining secretes mucus, which makes the walls slippery. Mucus also protects against bacteria and yeast overgrowth.
The effects of menopause-related vaginal thinning and dryness can be mitigated with over-the-counter products, gentle Kegel exercises and even safe and effective HT with estrogen.
Urinary incontinence and vaginal atrophy have a widespread impact. Despite the availability of effective treatments, they often go untreated due to embarrassment or dismissal of these symptoms as an unavoidable consequence of natural aging.
Urinary incontinence affects women twice as often as men
Postmenopausal European women with symptoms of vaginal atrophy
Effectiveness of Kegels for stress urinary incontinence compared to control treatments
Patients with vaginal atrophy who receive adequate therapy
Myths & Mysteries
Vaginal dryness, urinary incontinence and genitourinary syndrome.
Vaginal healthy aging can be had by using non-prescription lubes, HT with estrogen, and regular exercise with masturbation and intercourse.
There are many safe and effective non-prescription medications that can be used to lubricate your vagina. A vagina is a muscle, and it needs exercise..
Oh, please. Sexual preference is always that – a preference.
Kegel exercises, done routinely, help with stress incontinence in most women. It is helpful to do Kegel contractions when exercising, walking, stretching or during yoga.
Urine leakage can also be caused by damage done to the urethral sphincter during childbirth, as a complication of obesity and as a side-effect of urological surgeries such as a hysterectomy.
Vaginal atrophy and urinary incontinence can be improved in mid-life and late-life women. However, effective methods for encouraging women to speak on this issue remain hazy.
Where does this information come from?
1. Baber, R. J., Panay, N., Fenton, A., & IMS Writing Group (2016). 2016 IMS Recommendations on women’s midlife health and menopause hormone therapy. Climacteric : the Journal of the International Menopause Society, 19(2), 109–150. https://doi.org/10.3109/13697137.2015.1129166
2. Bulan, S. E. (2019). Physiology and Pathology of the Female Reproductive Axis. In Melmed, S., Koenig, R., Rosen, C., Auchus, R. & F. Goldfine (Eds.), Williams Textbook of Endocrinology (14th ed., pp. 574-641). Elsevier.
3. Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. The Cochrane Database of Systematic Reviews, 10(10), CD005654. https://doi.org/10.1002/14651858.CD005654.pub4
4. Minkin M. J. (2019). Menopause: Hormones, Lifestyle, and Optimizing Aging. Obstetrics and Gynecology Clinics of North America, 46(3), 501–514. https://doi.org/10.1016/j.ogc.2019.04.008
5. Kołodyńska, G., Zalewski, M., & Rożek-Piechura, K. (2019). Urinary incontinence in postmenopausal women – causes, symptoms, treatment. Przeglad menopauzalny = Menopause review, 18(1), 46–50. https://doi.org/10.5114/pm.2019.84157
6. The North American Menopause Society. (n.d.). Changes in the Vagina and Vulva. Retrieved July 11, 2021, from https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
7. Santoro N. (2016). Perimenopause: From Research to Practice. Journal of Women’s Health, 25(4), 332–339. https://doi.org/10.1089/jwh.2015.5556
8. Krause, M., Wheeler, T. L., 2nd, Richter, H. E., & Snyder, T. E. (2010). Systemic effects of vaginally administered estrogen therapy: a review. Female pelvic medicine & reconstructive surgery, 16(3), 188–195. https://doi.org/10.1097/SPV.0b013e3181d7e86e