Forty-two years old, Odessa is a typical patient coping with interstitial cystitis (IC). In excruciating pain, up off and on all night long to urinate, exhausted from lack of sleep and the chronic pain, having to urinate forty to sixty times a day, and tired of being told “there’s nothing wrong, you’re just stressed out,” she was dismissed by the urologist in her HMO who told her she didn’t need any more tests and said, “you just need to stop drinking so much water.” Odessa is one of the persistent women who did not give up. She finally found a urologist who knew something about interstitial cystitis, an acutely painful disorder found almost exclusively in women. She began getting appropriate help through a combination of medications and lifestyle modifications.
I first saw her two years after her initial diagnosis of IC when she had a consultation to explore the possible hormone connections with IC. She came in with the question “I have interstitial cystitis, could it be estrogen-related? I think I may be starting menopause.” I found that she indeed had both symptoms of low estrogen and objective signs: thinning of the vaginal lining, diminished breast size, decrease in pubic hair, and low blood levels of estradiol. Her bone mineral density had also decreased below normal for her age. She was a good candidate to begin a trial of low-dose estrogen therapy to help improve her health picture as well as to see what improvements could be achieved with her IC.
A year later, her sleep has improved, her energy and concentration are back to normal, her sex drive is back, and she reported that her frequency of urination had decreased by about 50 percent and the intensity of the bladder pain had also decreased. Her IC is certainly not gone, but it is better. Neither she nor I can say whether the improvement was due solely to the addition of estradiol, or to the combination of everything she was doing, but she said “It was encouraging to me to have my questions and insights taken seriously and included in my treatment.” Since estrogen has so many direct effects on the bladder lining, nerves, blood vessels, and muscles that govern urinary function, it made a great deal of sense to address this issue in her treatment.
Astoundingly, considering that IC is a woman’s bladder disorder, there is almost nothing in the scientific literature about the possible effects of hormone change in triggering it, or on the use of hormones as a part of the treatment approach. I was astonished to see a medical review article on current theories of cause and treatment for IC in a 1999 women’s health medical journal, written by a female urologist, and there was not one mention of ovarian hormone effects on the bladder. When you read further in this chapter and see what is known about the many effects of premenopausal levels of estradiol on the entire urinary system and its function, I am sure you will agree with me that such an omission is staggering. Every single IC patient I have seen has asked me this question “Could it be related to hormone changes?” Seems a pretty logical question, doesn’t it, if the problem is pretty much found only in females. I tell women that it makes physiological sense that there would be a connection, but there is little definitive research on the question.
Women are frequently embarrassed to tell me that they are having urinary problems, especially if they are experiencing incontinence or urinary “leaks.” This is truly a problem no one wants to talk about, yet urogenital problems are estimated to be experienced by as many as one half of women age fifty and up. The Heart and Estrogen/Progestin Replacement Study (HERS) in the United States found that 56 percent of the 2,763 participants reported weekly incontinence. It is much more common in the years just before menopause and gets gradually worse in the decades after menopause. Is this just due to aging? What is the connection to hormone changes? Another ironic twist: I reviewed many of the current books on menopause to make recommendations to my own patients for reliable resource information, and guess how many had chapters addressing urinary problems—only one. So this appears to be another overlooked, taboo topic even for women’s menopause books, even if written by women physicians.
Just like other organs and tissues in the body, the lining of the urinary bladder itself and the urethra have estrogen receptors. These lining cells are sensitive to the effects of rise and fall in estrogen levels during the monthly cycle, in pregnancy, and at menopause. Changes in estrogen cause measurable changes in the characteristics of the cells (cytology), changes in stimuli triggering the urge to void, changes in smooth muscle tone, changes in pain threshold that contribute to the intensity of symptoms experienced, as well as measurable changes in the pressure of the bladder and urethra (uro-dynamic changes). When estrogen levels decline and remain low, the cells lining the bladder, urethra, and vagina become fewer and thinner (atrophic) as well as more easily torn or damaged with friction (“friable”). The smooth muscle of the bladder, urethra, and vagina also contains estrogen receptors. When estrogen declines, the smooth muscle gradually loses its tone and strength. Lack of estrogen contributes to a decrease in the urethral closure pressure, which allows for more leakage. Nerve endings also contain estrogen receptors. With normal estrogen levels, the sensory threshold is raised. When estrogen levels decrease, the sensory threshold is lowered, and the nerve endings become more sensitive, leading to an increase in pain perception that in turn contributes to an increased urge to void.
There are also estrogen receptors in fibroblasts that synthesize collagen, the most abundant structural protein in the connective tissue of the female urogenital tissues. Loss of estradiol at menopause leads to loss of optimal collagen formation that in turn contributes to not only such visable signs as skin wrinkling but also loss of collagen support to help maintain urethral closure and avoid leaks. An interesting study correlating skin collagen with urethral function showed that increased skin collagen was associated with improved function of the urethral sphincter, a muscle circling the opening of the bladder and responsible for urethral closure.
As a result of these hormone-triggered changes in the lining tissues, women are much more susceptible to several problems, as shown in the chart below. When you look at how common all of the various bladder problems are for women, and the increase in such problems just before and after menopause, it is appalling that we still don’t have more controlled studies looking at the hormonal effects on these problems. Dr. Vicki Ratner, physician founder of the Interstitial Cystitis Association, acknowledged that women’s hormonal changes may play a role in this disorder but also says, “there’s just no research on this issue.” I have attended a number of medical continuing education meetings on women’s health issues, and I have heard presentations on IC, but not one has mentioned possible hormonal factors, even when they describe the disorder as being “epithelial (cells lining the bladder) dysfunction” or “immune dysfunction” (both affected by changes in estrogen).
• vaginal and vulvar dryness, itching, burning, stinging pain (several disorders: vaginitis, vulvodynia, vestibulitis)
• pain with intercourse (dyspareunia)
• recurrent bladder infections/inflammation (cystitis)
• urethral infections (urethritis)
• recurrent vaginal infections (vaginitis)
• incontinence (loss of urine—several types)
• painful urination (dysuria)
• urinary frequency
• urinary urgency
© Elizabeth Lee Vliet, M.D., 1995, revised 2000
Interstitial cystitis can be excruciatingly painful, and women often have to see a number of different doctors before being properly diagnosed. There are some staggering statistics with this disorder. Once thought to be relatively rare, current estimates from the National Institutes of Health put the number of sufferers at 500,000 women in the United States. This comes out to 1 in every 260 women. About half of these women are so adversely affected that they cannot hold down a full-time job, and over 75 percent cannot have intercourse due to pain. Fully one-third of women with IC have been abandoned by a husband or lover as a result of their illness. Even more sobering and alarming, fewer than one out of five sufferers have been properly diagnosed. Women have seen an average of eight to ten physicians before they are diagnosed. Even if we don’t focus on the human suffering involved in such an arduous search for help, what about the financial impact of individuals paying out of pocket and insurance companies paying for multiple doctors’ visits, not to mention lost time from work and other responsibilities?
Now some startling additional connections that support my theory that loss of estrogen is an overlooked factor in the development of IC: In a study of 374 IC patients published in 1993, researchers at Scripps Institute found that the mean age of onset for IC is forty-two years, and 44 percent of the patients had hysterectomies prior to onset of IC. What else happens in the decade of the forties? You got it, women are often beginning the climacteric time of hormone changes. What else is commonly associated with hysterectomies? You got it, women often begin an earlier ovarian decline of estrogen (even if the ovaries are left in place) due to the effects of surgery on blood flow to the ovaries. Other surveys of IC patients have found that flare-ups tend to occur after ovulation and just before menses. Both are times when estrogen levels are falling. Why aren’t these obvious hormonal connections put together and considered? Hormone changes are not the whole story; yet, I think it is a glaring omission to ignore the hormone issues altogether.
Part of the problem with IC is that many women suffer silently until the primary symptom, pain, becomes so severe that it interferes with normal activities. The characteristic symptoms of IC are, unfortunately, nonspecific and may occur in other kinds of bladder disorders: increased urination, sudden strong urges to void (urgency), intense pain becoming worse as the bladder fills up and often decreased by voiding (one woman called it “like passing fire”), pain with intercourse, having to urinate multiple times at night (nocturia).
A variety of possible causes are usually given, but at this time, we simply don’t have a definite answer. One of the common findings in women with IC is a history of repeated UTIs and repeated use of antibiotics over an extended period of time (another reason I urge women to avoid indiscriminately taking antibiotics). It has also been suggested that IC is due to a “dysfunctional bladder epithelium” (what about hormone effects here?) or a manifestation of an autoimmune disorder, which are also many times more common in females than males (again, what about hormone effects?). I must sound like a broken record, but it just amazes me that these obvious female connections are overlooked. Other proposed theories are that a toxic substance in the urine, or a chronic persistent infectious agent, damages the bladder lining, leading to the characteristic tiny hemorrhages in the bladder wall.
A large percentage of women are given antibiotics in their primary care or gynecology settings, but most IC specialists agree that antibiotics help this condition very little. Yet many women whose IC has not been properly recognized have been told that they have recurrent bladder infections in the wall of the bladder and need to be on extended courses of antibiotics. In addition to the expense of unnecessary medication, these women often end up with difficult-to-treat yeast infections.
A variety of other medications have been tried for IC, with varying degrees of success. An oral medication, (1) Elmiron (pen-tosan polysulfate or PPS), is a heparinlike compound that provides a protective coating of the bladder lining. The success rate with Elmiron is about 45–50 percent. This drug, given orally, usually 100 mg three times a day on an empty stomach, has few side effects, which are generally reversible when dosage is stopped. Elmiron is somewhat expensive, and it usually takes about three—six months of therapy before symptoms improve. FDA approval for Elmiron in treatment of IC was granted after three U.S. trials indicated that it was more effective than placebo. Other oral medications include: (1) Anti-inflammatory medications (NSAIDS) for pain relief; (2) antihistamines to reduce mast cell activation, such as hydroxyzine, (Atarax, Vistaril) show promising results so far; (3) nalmefene; (4) amitriptyline (Elavil and others), a tricyclic antidepressant that also has good pain-relieving properties. (It is also an antihistamine and its anticholinergic properties reduce frequency of bladder emptying.) Amitriptyline has been shown in several trials to be effective, with the usual dose 25–75 mg at bedtime, but there are side effects of sedation, dry mouth, constipation, and significant weight gain.
Intravesical therapy, or bladder distension by filling with fluid, is another approach used for more severe cases of IC. The bladder is distended at 80 cm of water pressure for two to eight minutes, under anesthesia. Some patients report worsening symptoms for a few days, then experience improvement. This relief usually lasts about six–twelve months, and a repeat distention usually again provides a period of pain relief. This form of treatment is one of the oldest known treatments for IC. Until Elmiron, the only FDA-approved medication was DMSO (dimethyl sulfoxide) injected into the bladder (usually 50 ml of 50 percent solution). Symptoms were significantly improved in about 50 percent of the patients. Patients typically receive a treatment on a weekly or monthly basis for six to ten sessions, followed by maintenance treatments less often. One problem is that patients become progressively resistant to it over time. Other drugs inserted directly into the bladder may cause pain and must be done under anesthesia. These include silver nitrate, adriamycin, lidocaine, and chlorpactin WCS-90. Obviously, you should seek out a highly skilled urologist, with experience in treating IC patients, before you undergo these treatments.
“Robbie” is a forty-three-year-old woman who came for a consult describing “Severe vaginal burning, painful intercourse, lack of lubrication, and diminished orgasm.” She said that after reading my book,
I felt like finally someone was hearing what I was saying. I have been through the mill—I have been to seven or eight different doctors. I went to two different Gynecologists and they said I should see a urologist, who put a scope up my bladder. One Gyn checked an estrogen level but it was a random cycle day. I was told it was normal, but after I read your book I realized it probably wasn’t reliable because no one had asked where in my cycle I was. I even had an MRI and they didn’t find anything. I went to a specialist at S____ Clinic for vulvodynia and all they did was give me a prescription for citrate and glucosamine. It has helped some but I still had the burning. I am a very bright woman and I wouldn’t give up, I felt like they were just treating the symptom not getting at the cause. The doctor at S____ Clinic was even doing surgery on women to remove the damaged tissue. I didn’t want to go that route. I then had a reading with a woman who is a medical intuitive, and she said the vulvodynia was due to my having problems with boundaries because I had been in a very stressful relationship for two years. By this point, I didn’t know what to think and that’s when a friend told me about your book.
I explained to Robbie that there are many biological endocrine factors causing vaginal and bladder problems in women with declining estradiol, and I do not agree with attributing problems like vulvodynia to purely psychological causes and making pronouncements like it is caused by “boundary problems.” To my way of thinking, this is again victimizing the woman by blaming her for causing the medical problem, and I do not think this is a very helpful approach.
An interesting fact came to light when I explored with Robbie what her dietary habits had been over the years she was having problems with vulvodynia. She said “I changed to a high soy diet. I started maxing it out, buying tofu and eating it all the time, drinking soy milk—for about two years before the vulvodynia developed. I stopped drinking milk—I heard soy was so good—I changed everything to soy.” Otherwise, her diet and lifestyle habits were quite good; she did not use alcohol or tobacco, and exercised regularly. I explained that new studies from three different countries have found that high intake of soy phytoestrogens actually inhibit normal ovarian function in premenopausal women, causing anywhere from 20–50 percent decrease in women’s own ovarian hormones, estradiol, and a progesterone. In addition to age, I explained that her high soy intake and low-fat diet were two more factors contributing to her ovaries making less estrogen. It is important to remember that your hormones are made from cholesterol as a basic building block. You must have adequate amounts of cholesterol or your body can’t make its steroid hormones (estradiol, progesterone, testosterone, DHEA). Your liver will manufacture cholesterol from food you eat, and from triglycerides, even if you don’t eat foods high in cholesterol. Robbie had been on such an extremely low-fat diet for so many years that her body simply didn’t have the building blocks it needed to make enough of her ovarian hormones. And then all her soy intake “competed” at the estradiol receptors with what little estradiol her own body did make. Ultimately, the loss of adequate estradiol adversely affected the health of her vulva, bladder, and vaginal tissues.
She also had gone through a lot of infertility treatment and had six months of Clomid, 4 cycles of Pergonal, an in-vitro attempt, and a GIFT (gamete intra-fallopian transfer) procedure. She never became pregnant, but the hyperstimulation of her ovaries meant that more of her follicles were depleted at a younger age than usual. This is another factor adding to her premature loss of estradiol. Her rather marked life stresses added to the premature suppression of her ovaries with diminished hormone production. Remember that stress-induced suppression of the ovaries is part of Mother Nature’s protective effects to prevent reproduction when the person (or animal) is not optimally healthy to carry a fetus through a pregnancy. I have to wonder about the possible connection between the last decade of emphasis on very low-fat diets, high soy intake, busier and busier lives with lots of stress . . . and the sharp rise in young women with vulvodynia, infertility, and other hormonal problems I am seeing in my practice.
Checking her hormone levels clearly showed this pattern. Her Day 1 estradiol was 22 pg/ml, when it should have been about 80–90 pg/ml. Her Day 20 estradiol was 156 pg/ml, about half the optimal level for a luteal phase peak in an ovulatory cycle. Her progesterone, in contrast, was at a normal, healthy ovulatory level on Day 20, so she was not progesterone deficient even though her estradiol was too low. Her testosterone was quite low at 10 ng/dl. Her DHEA was really higher than usual, so she did not need this hormone supplemented. All of the rest of her laboratory studies were quite good, including detailed tests of adrenal, thyroid, liver, and kidney function.
It was striking to notice that Robbie’s vulvodynia pain flared each month at the time of her cycle when her estradiol was the lowest, at menstruation. The drop in estradiol causes the pain threshold to be lower, so that pain occurs with less stimulation. Low estradiol levels also cause more tissue dryness and burning. In addition, as estradiol declines, stomach pH is altered in such as way that there is less absorption of calcium and magnesium from dietary and supplement sources. If these minerals aren’t present in optimal amounts, this is another factor in pain symptoms being worse. I suggested that she try a low-dose hypoallergenic estradiol cream topically to the vulvar area nightly to restore the tissue estradiol more directly, a low-dose estradiol vaginal ring (Estring) inserted inside the vagina near the cervix to reduce the vaginal dryness, and a transdermal estradiol (Vivelle DOT 0.05 mg) patch to bring her serum levels back to the healthy ranges. She had tried Estrace vaginal cream without success, saying that it caused an increase in the burning and vulvar pain. I was not surprised by this report, since all of the FDA-approved commercial estradiol creams contain a chemical (polyethylene glycol, or PEG) that causes a lot of burning when sensitive tissues are damaged by loss of estrogen. I recommended that she use a topical estradiol cream made especially without PEG, and this was compounded at Belmar Pharmacy in Lakewood, Colorado.
When I had a follow-up appointment with Robbie about six weeks later, she said “I had a lot of burning initially with the cream and the Estring, but I stuck it out. Now everything feels much better, the pain is much less. I still have a lot of vaginal dryness but it is slowly getting better. I felt like I had razor blades with the vulvodynia, and that intense pain is gone. I took all your information to my vulvodynia specialist and he said Dr. Vliet is right on. I asked him why he hadn’t tested my hormone levels and he said he thought my Gyn had already done them! I told him that he should check hormone levels on everyone who comes through his door!” She was pleased to be feeling so much better so quickly, and could tell she was on the right track. But since her symptoms had not fully resolved and her serum levels of estradiol were still too low, I recommended an increase in her estradiol patch to the 0.1 mg strength and she agreed this made sense to her.
Her next appointment was three months later, and at this time she said “I am coming along really well—the pain with that burning is really low—that burning like razor blades when I urinate is totally gone now. I have some mild pain now at times but nothing incapacitating like it was. It is so much better now with the estrogen! This is just wonders for me.” It became time to add natural progesterone because her own ovary production began to decline, and I recommended Prometrium 200 mg a day for twelve days every other month. This produced a normal pattern of bleeding each time, and she tolerated it very well.
I received a follow-up letter from her three months after this second appointment, and she said (in big bold letters): “My pain is still 98% gone for the last 7 months! Thank you truly for your excellent care of me. You have helped me so much. I am doing so much better on the estrogen.” She went on to comment that she was really shocked that no one had checked her hormone levels before this, and she planned to talk with her doctors about how important this is for women. She ended her letter with “My health was regained by me listening to my own inner guidance and intuition of what was right for me.” Has your doctor run thorough tests of your hormone levels?
Certain foods are potent bladder irritants, and some experts recommend that the following culprits be eliminated or reduced: caffeine, alcohol, tobacco (nicotine), chocolate, spices and spicy foods, apples, bananas, acidic foods (citrus fruits, tomatoes), NutraSweet and saccharine, sharp cheeses, coffee, tea, carbonated beverages, chemical preservatives (found in many foods and beverages), lima beans, lentils, and yogurt, to name a few. These foods produce metabolic by-products that may irritate bladder mucosa and increase the urinary urges to void, increase urinary frequency, which in turn end up aggravating incontinence. These foods also cause bladder spasms and pain in some women. Not only are alcohol and tobacco themselves potent bladder irritants, they also significantly interfere with the metabolism and effectiveness of prescription hormone therapies. Diets that are too low in fat reduce absorption of oral ovarian hormones, while diets that are high in fat will increase absorption if taken at mealtime. Thus, bioavailability of any given oral hormone therapy will be affected by when it is taken relative to a meal and the type of meal consumed. When you stop and think about the typical diet of many women “on the run” with busy schedules, you begin to realize just how many of these triggers most people consume every day. Many of my patients obsess over an extra gram of fat, and then drink cola beverages all day that contain a wide variety of irritant chemicals, not to mention all the calories from sugar.
Keeping a dietary diary, correlated with your bladder symptoms, often helps identify the food culprits so you can make the necessary modifications in what you eat and drink. If you are having bladder problems, it really helps to clean up your diet.
It was during my specialty training at Johns Hopkins that I first became aware of how potentially serious, and bizarre, patients’ reactions can be to something as seemingly innocuous as the coloring agents used in medicines (even vitamins and herbal products can have coloring agents that cause these problems). My mother had been researching the role of dyes in atypical allergic reactions at about the same time I had a patient with asthma admitted to our service. In the course of treating the patient’s admitting illness (not his asthma), his asthma kept getting worse. We could not figure out what was happening, since his asthma medications were the same and blood levels were therapeutic. Based on the work my mother was doing, I raised the possibility that perhaps it might be the orange-colored tablets we started using to treat his other illness. We changed to a different brand of the medication (one with a white tablet), and within a short period of time, the asthma cleared. Since the patient was as curious as we were as to whether the culprit had indeed been the orange dye in the first tablet, he agreed to try taking it one more time. The wheezing returned rapidly. No more orange dye for this person. All of us learned an important lesson.
I started collecting whatever information I could on tartrazine-based dyes (a common one is FD&C yellow #5) in medications, foods, and beverages. I was able to find a few articles on allergic reactions to these compounds. The tartrazine-based dyes have a similar chemical effect in the body to that occurring with salicylate, the chemical name for aspirin. Many people who are allergic to aspirin may also react to tartrazine but often don’t know it. Since dyes like FD&C yellow #5 are found in so many common products, even including medications used for asthma and allergies, people may be getting a daily dose of a chemical they are allergic to and not realize it. These dyes have metabolic breakdown products that are excreted in urine and are a potent trigger for “irritable bladder,” leading to incontinence, that many do not think to check. Over the course of my medical career, I have found this to be a much more common problem than I had ever been taught, and so I have included these cautions in many of the educational programs I do for other physicians. I have seen reactions from rashes to wheezing to severe bladder spasms, all traceable to the dyes in a daily medication.
Janie was an energetic woman in her late forties who came for a consult about her bladder spasms, which had progressed to the point that she had to catheterize herself several times a day to urinate. She had been hospitalized on several occasions with such severe bladder spasms that she had been unable to void at all. She had been healthy, without any history of bladder problems, until about two months after she started estrogen therapy with Premarin. The estrogen effectively relieved her menopausal symptoms of hot flashes and sleeplessness, but she started to develop new symptoms of increased frequency of urination, sudden urges to void, and a burning pain in the area of her bladder. She had seen multiple doctors; had been treated with many courses of antibiotics, pain medications, and tranquilizers; and had been told she was obviously having emotional trouble over her children leaving home, so she should see a therapist. Meanwhile, nothing seemed to help. Janie was having such frequent spasms and difficulty voiding, she had been taught to catheterize herself.
During her visit to our women’s health program, she had planned to pursue biofeedback training and acupuncture to help decrease the spasm and pain. In our consultation, she said, “You know, it sounds silly, but I keep wondering if this problem could have any connection to starting the Premarin. Before that, I never had anything like this. I’ve asked all my doctors this question, but they have all said there’s no connection, or it’s not possible.” I told her that I had seen problems like this, due not so much to the drug or hormone but to the dyes in the tablet. I explained that the simple way to test her idea would be to change her to a completely dye-free form of estrogen and see if it made any difference over the next few months. At that time, there were no commercial estrogens on the market in the United States that were free of dyes. That in itself is amazing and disconcerting to me, given the number of women with allergies, who may need estrogen. So I called the pharmacist in Colorado who had compounded individualized prescriptions of natural hormones for some of my patients and asked him if his tablets had any dyes. They did not, so I ordered the dye-free estradiol tablet for Janie to try.
She was so excited that someone thought she could be on to something that might help, she had it sent overnight mail. I had already told her not to get her hopes up, since this might not be the cause of her bladder problem, but I did think it was worth trying. I also told her that if the dye was an irritant to her bladder, it could still take several weeks for her to see any difference with the change in estrogen tablets. Three days later she called me, and practically yelled over the phone “It’s GONE. I have actually been able to urinate on my own without the catheter. This is amazing.”
Even I was astonished at the rapid response. I have seen some pretty surprising improvements over the last fifteen years of working with patients, but none this fast. It is now two years later, and at the last follow-up I had with her, her bladder spasms had resolved, and she had remained on the dye-free estrogen. Doctors should be willing to make a simple change like this to a different tablet without dyes and see how this affects symptoms.
These same azo-tartrazine dyes are known carcinogens and skin irritants, and some have now been banned due to these effects. My suggestion to you is that if you have bladder sensitivities and an “irritable” bladder (or bowel), it may be wise to watch for these types of chemicals in the foods, beverages, and medicines you consume. Another common irritant for many women is the propylene glycol in various vaginal creams, including some of the estrogen vaginal creams that are used to help treat vaginal itching and burning. Use of a vaginal 17-beta estradiol cream in a hypoallergenic base without propylene glycol may also help alleviate these problems. Such creams have to be obtained from compounding pharmacies, since all of the commercial estrogen vaginal cream products contain propylene glycol, which may be significantly irritating to tissues.
If you have persistent problems with these symptoms, talk with your physician or pharmacist to see if what you are using contains these dyes and other chemicals. The Physicians Desk Reference is now required to list these dyes and other inactive ingredients, so you can always ask your pharmacist if you are in doubt about a particular medicine. Many food manufacturers will send you a complete ingredient list of their products if you write to their consumer information office.
I am very concerned about the trend of women calling doctors’ offices for help with “bladder infections” and getting repeated courses of antibiotics. First of all, burning, frequency, and urgency may have many causes. Not all causes are due to infections. Second, repeated use of antibiotics creates problems with resistant bacteria and with chronic yeast infections. So make sure you take the responsible course of action, and go see your doctor for a urinalysis and urine culture before you start on antibiotics. I also think it is important to have your hormone levels checked if you are having problems with burning, frequency, urgency, or leaking of urine. Many people still don’t realize the degree to which loss of estrogen plays a role in causing these changes during and after menopause. Rather than continuing to think you have an infection and taking antibiotics, I think it is far more effective to assess the possible hormone causes and address this problem directly, perhaps first with a vaginal estrogen cream or by taking one of the hormone therapy regimens if your doctor feels that is appropriate for you.
If estradiol blood levels are below the 50–60 pg/ml range, it is highly likely that this is a major cause of the urinary problems. Occult diabetes is another very common cause of urinary problems in older women, especially if you are overweight. In its early stages, before the fasting glucose is significantly high, frequent yeast infections, burning on urination, increased frequency, and leaking of urine are common. If you have a family history of diabetes, or have noticed an increase in craving for sweets, you should talk with your doctor about checking more closely for diabetes. In patients I see for consultations, I find that these two endocrine changes are the most frequent unrecognized causes of persistent urinary problems.
In addition to the hormone levels, there are some other important tests that you should discuss with your doctor. Not every patient will need all of the tests, but you should at least ask whether any of these are needed to determine the cause of your problem if your doctor doesn’t mention them. This is not an exhaustive list, since there are many medical problems that can cause urinary problems. But at least this list gives you an idea of some of the newer techniques that are available to aid in the diagnosis of urinary disorders.
Continence is the ability to control urine flow, and hold urine in the bladder when you feel an urge to urinate. Once we are toilet trained as children, most of us control urination urges unconsciously as we go about our daily activities. Accidental loss of urine, or difficulty controlling the urine flow, is called incontinence. A tragic aspect of incontinence problems is the degree to which women do not know it is a treatable problem. For example, it is a widespread misconception that urinary incontinence is an inevitable part of normal aging. This is not correct. The Alliance for Aging Research says it best:
“You should never think of incontinence as something you have to put up with, or as just a part of growing old.”
And it’s not just the issue of comfort that is at stake. Urinary incontinence has a devastating economic impact, individually and collectively, in this country. Americans spend more than $10 billion annually on products to either hide the problem of incontinence or to help them cope with it, without looking for ways to treat or eliminate the cause. Medicare cost projections for medical diagnosis and treatment of urinary incontinence are even more staggering: $26 billion annually, more than the costs for dialysis and coronary artery bypass surgery combined. And since this figure includes only the costs for people over sixty-five, the total costs are even greater when one includes the prevalence in younger persons, due to pelvic surgery such as hysterectomy. For older women, the issue carries additional significance: Loss of bladder control is one of the more frequent causes for nursing home admission. Once in a nursing home, patients are even less likely to have a thorough diagnostic evaluation; they are “managed” with catheters and repeated courses of antibiotics, both of which have potential adverse consequences.
With our current knowledge of the causes, and variety of diagnostic and treatment options (and definitely not always just using drugs and surgery), better than 50 percent of incontinence patients can be cured, another 35 percent markedly improved, and the remaining 15 percent made more comfortable. Please do NOT sit home and suffer in silence if you have this problem. See a knowledgeable, caring, and competent physician, or call one of the resources at the end of my book to locate an appropriate professional near you.
There are different types of incontinence, and it helps to understand the characteristics and causes of each.
Stress incontinence is one you hear often, and patients are frequently confused about what it means. I remember one woman in her seventies who came to see me, and when I asked her what was bothering her, she burst into tears and said “My doctor told me I had stress incontinence. I know it’s real, and it’s not just stress in my life.” Her doctor, I am sure, had no idea how upset this lady was by his use of a medical term that she misunderstood to mean something very different, and she was too embarrassed to ask what her doctor had meant. “Stress incontinence” does NOT refer to emotional factors causing loss of urine. It means the loss of bladder control due to the physical stress of increased pressure in the abdomen from such activities as laughing, coughing, sneezing, sexual orgasm, jogging, or straining to have a bowel movement.
This type of incontinence is not caused by bladder spasms; it results from weakness or loss of tone in the bladder muscles, which is primarily due to mechanical factors such as damage to the bladder muscles in childbirth, or ligaments and muscles weakened by age or loss of hormone or nutritional components necessary for healthy tissue. Stress incontinence may also be due to hormonal decline contributing to loss of muscle tone. In addition to the effects of estrogen loss seen in postmenopausal women, 35 to 40 percent of women experience postpartum stress incontinence for as long as six to twelve weeks after childbirth due to trauma to the bladder muscles and the sudden drop in hormone levels after delivery. Stress incontinence is usually not associated with urinary frequency and urgency.
Urge (urgency) incontinence is defined as the sudden urge to urinate and the inability to hold your urine long enough to reach the bathroom. It usually results from bladder spasms, and is associated with both increased frequency and urgency. It is common for of urge incontinence to occur without a clear-cut physical cause, but it may also be caused by serious medical conditions such as herniated inter-vertebral disks, bladder infections, or by gynecological problems such as fibroids exerting pressure on the bladder or loss of normal estrogen effect on urinary and reproductive tissues. Urge incontinence is also aggravated by habits that cause increased urine formation, such as excessive fluid intake, alcohol, use of diuretics (“water pills”), beverages with caffeine, and/or tobacco use. It is important to see a physician for a thorough evaluation, because bladder cancer is also a cause of urge incontinence that has to be ruled out before proper treatment is started. It is not a good idea to keep taking antibiotics for urinary tract infections (UTI), a common cause of urge incontinence, without having a careful medical evaluation to find causes that may need different treatment approaches.
COMMON CAUSES OF URGE INCONTINENCE
• urinary tract infections
• bladder inflammation
• estrogen deficiency
• spinal nerve-root disorder (e.g., disc disease)
• pelvic irritation
• chemotherapy
• spinal cord injury
• pressure from uterine fibroids
• emotional stress
© Elizabeth Lee Vliet, M.D., 1995
Mrs. G. was a seventy-two-year-old professional woman in New York who had a thriving business to run. She came to see me for a variety of health concerns, including bone loss and incontinence. She wanted to discuss the possibility of estrogen replacement therapy. She had been told by her doctor that her incontinence was “to be expected, it’s what happens when you get older, just wear pads.” Needless to say, this was a difficult idea to accept and a source of embarrassment and anguish for her. Gynecological urology is not my specialty, but I knew that she needed a complete evaluation of her incontinence and this had not been done by her own physician. I referred her to a specialty center in Baltimore, and after the proper diagnostic studies, she was found to have a very treatable type of urge incontinence. She was started on a medication regimen in addition to the hormone therapy I had prescribed. Six months later, her incontinence had dramatically improved to the point where she rarely had any more accidental episodes of urine loss.
Overflow incontinence is the accidental loss of urine from a chronically full bladder. A common cause is a cystocoele, which is a vaginal hernia or bulge due to weakened vaginal muscles seen often in postmenopausal women. The bulge from the cystocoele makes a mechanical obstruction and prevents complete emptying of the bladder. A woman can then lose small quantities of urine when she stands, sits, or bends. Another cause of overflow incontinence is damage to the bladder nerves from diabetes, loss of adequate estradiol effects, or from a herniated lumbar disc. This is what happened to me when I was twenty-eight, before I was correctly diagnosed with the lumbar disc. I can certainly relate to the embarrassment caused by episodes of incontinence and the frustration patients experience trying to get help. Overflow incontinence is treated by identifying and resolving the underlying cause. Pessaries, a device inserted into the vagina as a supportive structure, may sometimes be used to lift the bladder away from an obstructed outlet, or bladder surgery may be needed to repair a cystocoele. In my situation, removal of the herniated disc, and getting the pressure off the spinal nerves, allowed normal nerve function to return and the incontinence resolved. As you can see, it is important to distinguish which type of incontinence you have, because the effective treatments are different, for example, stress incontinence is often relieved by bladder surgery, but urge incontinence is not. Loss of urine at night may also occur from a combination of the above types of continence dysfunction.
Some types of incontinence are quite responsive to hormone therapy to restore the estrogen effects on bladder lining, bladder and urethral smooth muscle, connective tissues supporting the bladder, et cetera. There are a few double-blind, placebo-controlled studies that have compared the effectiveness of estrogen therapy in treating urinary urgency, frequency, urge and stress incontinence. These studies have used several types of estrogen: estriol, 17-beta estradiol, and conjugated equine estrogens. To date, the results are mixed. There are several studies from Europe that have shown that all of the three types of estrogen above can improve symptoms of burning, urgency, and frequency; but estrogen therapy alone has not shown a consistent positive effect on stress incontinence. In the studies I was able to locate, the authors commented that the doses of estriol used may have been too low to achieve optimal benefit. I also thought that the amount of estradiol used was low compared to what we typically recommend for heart and bone benefits. Until we have more definitive scientific data, it is clear that being estrogen-complete for our postmenopausal years does improve and enhance many functions of the urinary bladder, urethra, and vagina, even if estrogen doesn’t solve all problems. This is a factor you should explore with your doctor. Don’t be afraid to bring it up. Prompt diagnosis is crucial so that a treatable problem can be addressed in time. In my case, if the problem had gone unrecognized another few days, I would have permanently lost the nerve control of my bladder and been left with having to use a catheter the rest of my life.
COMPONENTS OF A DIAGNOSTIC EVALUATION
FOR INCONTINENCE
• detailed patient history
• food/beverage intake diary, and urinary voiding diary
• use of prescribed and over-the-counter medications (and herbs, vitamins, minerals, etc.)
• physical examination
• blood chemistries, hormone levels
• urine culture
• urine cytology (rule out cancer)
• postvoid residual urine volume (measures urine remaining in bladder after voiding, which can contribute to incontinence)
• ultrasound (assess kidney size, structure to look for tumors, etc.)
• urodynamic studies (check for filling and emptying patterns)
• voiding cystourethrogram (checks urethra pressures)
© Elizabeth Lee Vliet, M.D., 1995, revised 2000
If you are already on ERT or HRT and are still having problems with bladder symptoms like I have described, you may want to ask your doctor to check blood levels of FSH and estradiol to determine whether you are taking the right amount of estrogen for your body needs. I continue to find that what we thought was an adequate dose turns out to be less than what’s needed for many women. If you are still bothered by symptoms, it is especially important to determine if you are on the right amount of estrogen, because you may not be getting enough for estrogen’s other benefits either. If serum estradiol levels drawn about twelve hours after a dose of oral medication or on the last day of a transdermal patch are below about 70–80 pg/ml, it is likely that suboptimal estradiol is a factor in the persistence of urinary symptoms. I typically aim for estradiol blood levels of over 100 pg/ml, which is what is typical for the first part of the menstrual cycle. If your ERT/HRT regimen provides estradiol blood levels over 100, the FSH will usually come back down to 35 or less. A residual FSH greater than 20 with estradiol levels below 80 pg/ml confirm the suboptimal estrogen replacement. Vaginal pH may also be a factor. Hypoestrogenic effect and recurrent urinary and vaginal infections are associated with pH levels greater than 4.5 to 5.0. I find these objective measures very helpful in deciding about doses for individual women, especially if they are still having urinary problems.
Another pointer, which I have found helps some women: if you are taking estrogen and continue to have bladder irritation symptoms of burning, frequency, and urgency, you may find it helpful to ask your physician to prescribe an estrogen without dyes in the tablet. Many of the chemical dyes used in medications (and foods and beverages—see earlier section) are irritating to the bladder lining. Looking for dye-free (usually white) tablets for your medications can reduce this source of additional irritation to the bladder. This is a fairly easy step to take, and it may give significant relief. For those of you using a transdermal patch, be aware that some patches actually decline sooner than the manufacturers indicate, which means erratic estrogen levels that can lead to the return of urinary symptoms. A simple strategy to alleviate this problem is to change the patch sooner to give better stability in estrogen replacement.
Another option is to change the type of estrogen you are taking. Women have many individual differences in absorption and metabolism of foods, hormones, vitamins, and medications. We have to take this into account. The standard estrogen your doctor uses simply may not be well absorbed in your body, and you can ask to change to a different one to see if this helps your symptoms. The equilin or horse-derived estrogens have different binding properties and actions at the estrogen receptors, and these estrogens are also more difficult to metabolize by the human body, since women lack key enzymes in this process. As a result, a number of the equine estrogens remain in the body far longer than does estradiol or estrone. These factors may contribute to incontinence and bladder problems. You may find that a native human 17-beta estradiol works better than the mixed estrogens. In chapters 2, 5, and 15, I have information on the different 17-beta estradiol and the mixed-estrogen preparations available in this country.
Selected pharmacies in the United States will also compound estriol tablets and creams, which your physician may consider adding to your ERT/HRT regimen if needed. Estriol has a very short retention time of only one to four hours in cells, making it unlikely that once-a-day doses will provide adequate estrogenic effects when compared to estradiol or estrone. A few studies from Europe have found, however, that intravaginal use of topical estriol cream is of some value in treating vaginal dryness and milder forms of incontinence. Vaginal estriol has been considered by some to be a form of estrogen delivery to urogenital tissue that is safe for breast cancer patients, although long-term clinical trials regarding safety and efficacy have not yet been determined. I do not recommend taking estriol without your doctor’s knowledge and without adequate monitoring of estrogen effect, since too much estrogen may lead to increased risk of uterine (endometrial) cancer. Phytoestrogens as they naturally occur in foods are too weak to have significant impact on bladder function and incontinence. Although the phytoestrogens are less potent than 17-beta estradiol, it is quite easy with the use of many supplements currently available to produce much higher serum concentrations of the phytoestrogens that competitively inhibit the action of 17-beta estradiol at cellular receptor sites. Dietary and supplement intake of the phytoestrogens are another potential confusing variable in studies of estrogen effects on urogenital measures.
When viewing studies of estrogen effects on bladder function and incontinence, it is important to determine which form of estrogen has been used, since potencies and receptor actions can be quite different. In my clinical experience, optimal effects on bladder are difficult to achieve without having optimal serum levels of the premenopausal estrogen, 17-beta estradiol. Clinical studies that do not measure serum hormone levels, or that use predominately an estrone form of estrogen therapy, may fail to show clinical benefit on incontinence more as a result of suboptimal estradiol replacement than as a result of lack f estrogen effect per se. In addition, multiple studies from many menopause research settings worldwide over the last three decades have found that route of administration of estrogen makes a significant difference in the therapeutic effect on incontinence. For example, the systemic absorption of low-dose estrogen preparations applied vaginally is dependent on the status of the vaginal mucosa. Absorption is high when the vaginal mucosa is atrophic and gradually decreases to near zero as the vaginal mucosa matures under estrogen influence. Using different routes of estrogen delivery is another issue that makes direct comparison of various studies difficult, since some studies focus on oral delivery, others employ transdermal skin patches, and still others assess intravaginal delivery forms.
Since there is so little written on such an important subject, I am including a summary of the few double-blind, placebo-controlled studies that have compared the effectiveness of estrogen therapy in treating urinary urgency, frequency, urge and stress incontinence. These studies have used several types of estrogen: estriol, 17-beta estradiol, and conjugated equine estrogens. To date, the results are mixed. There are several studies from Europe that have shown that all of the three types of estrogen above can improve symptoms of burning, urgency, and frequency; but estrogen therapy alone has not shown a consistent positive effect on stress incontinence. This lack of consistency in the various study results, in my opinion, may be related in part to having suboptimal levels of estradiol due to the type and dose of hormone preparation used. In some studies, authors have commented on this dose effect, and in others, dose-response and type of estrogen issues have not been addressed. Several studies used doses of estriol that were too low to achieve optimal benefit, and this same problem appears to have been the case in some studies using estradiol, since the amount used was low compared to what is typically recommended for cardiovascular and bone benefits.
Yet other authors have found significant clinical benefit on incontinence with various forms of estrogen. The consensus of their studies is that hormonal supplementation with estrogens must be viewed as critical to the relief of this impairment in bladder function. A prospective study of continuous combined hormone replacement using 17-beta estradiol and dydrogesterone (a direct progesterone derivative) found that 23.3 percent of the participants reported being cured of their incontinence and nighttime incontinence disappeared in 65.4 percent after six months of oral hormone therapy. At the initiation of the study, urinary incontinence was reported by 44.1 percent of the women, and urinary frequency was reported by 28.4 percent of the women. The authors found that addition of the progesterone derivative did not diminish the effectiveness of estrogen. The results of the above studies correlate with my clinical experience as well.
In spite of such positive findings as those above, a large double-blind placebo-controlled study from England published in 1999 using 2 mg daily of estradiol valerate did not show improvement in urinary stress incontinence when compared to placebo. At least three factors, based on my experience, may contribute to the observed lack of improvement with estrogen in this study: (1) use of the synthetic estradiol valerate in an oral form resulted in conversion to estrone in the liver, inhibiting optimal serum levels of estradiol; (2) the once-a-day dose allows estradiol levels to fall significantly prior to the next dose, which diminishes the estrogen effects on urogenital tissue; and (3) serum estradiol levels were not done to determine whether optimal levels above target thresholds were achieved.
Dose, type of estrogen used, and route of administration have all been found to be significant in determining optimal response on urinary symptoms. Many gynecologists and menopause specialists report that their clinical experience has been that intravaginal delivery has generally been a more effective route of administration of estrogen for the benefit of the urogenital tract rather than oral routes. The estradiol vaginal ring delivery system (Estring), in combination with a 17-beta estradiol transdermal patch for systemic effects, has been particularly effective in my experience. Estring contains 2 mg of 17-beta estradiol in a silicone ring, smaller than a diaphragm, and is intended to remain in place for three months to deliver a low daily dose of the estradiol directly to the urogenital tissues. Some women, however, note a return of symptoms at about two months of having the ring in place, and find it helpful to change the Estring early if this happens. The vaginal ring system has the added benefit of providing mechanical support at the same time it delivers the daily low-dose estradiol. Vaginal creams are also quite helpful to these patients, although somewhat less pleasing esthetically than the vaginal ring system. Vagifem is a vaginal tablet containing 25 micrograms of 17-beta estradiol that has been well-tolerated and effective. In a twelve-week double-blind, randomized, placebo-controlled study, researchers found that treatment with Vagifem significantly improved frequency, urgency, urge, and stress incontinence compared to a placebo. In actual practice, Dr. Boyd, our gynecologist reports that as little as 0.5 to 1.0 gram of 17-beta estradiol cream inserted into the vagina nightly three to seven times a week has provided significant improvement with incontinence in about 50 percent of his patients. Types of incontinence other than stress incontinence have shown the greatest improvement, although modest improvements have been found even in stress incontinence. The vaginal route of administration at these low doses has the added advantage that very little of the estrogen is absorbed systemically (into the whole body). It appears, therefore, that this option may be safe to use in patients for whom systemic estrogen therapy has not been tolerated or is not an option for other medical reasons.
There has not been a great deal of attention yet paid to the urogenital effects of progesterone, synthetic progestins, or testosterone and the role that these hormones may play in causing beneficial or adverse effects on incontinence and other urogenital problems associated with menopause. There is evidence from a wide variety of studies on progestins that these compounds reduce estrogen binding at the estrogen receptor sites in different target tissues and may therefore serve to oppose estrogen effects. I have not been able to locate formal studies of such phenomena with regard to incontinence. My clinical experience, however, has been that women on estrogen replacement therapy have increased problems with urinary infections, frequency, urgency, and all forms of incontinence during progesterone or progestin phase of hormone replacement therapy or with use of progestin-dominant oral contraceptives. My clinical approach has been to slightly increase the amount of estrogen given during the progestin phase of therapy in order to overcome the negative effects of the progestin. This strategy has helped avoid relapse of urinary symptoms in women who had achieved improvement during the estrogen-only phase of their hormone therapy.
The following are strategies I used for my patients in fine-tuning hormone therapy to give better relief of interstitial cystitis pain, vulvodynia, vestibulitis, and the various types of incontinence. You may want to explore these options with your own physician to help improve urinary system symptoms:
Dr. Vliet’s Guide: Optimizing Hormone Therapy to
Help Bladder Problems
• Monitor serum levels to ensure that estradiol levels are adequate and are above the known minimum thresholds for estrogen’s multiple benefits.
• Intravaginal delivery systems (Estring, Estrace cream, Vagifem) give maximum desired effects on urogenital tissues with less total body absorption (and therefore fewer side effects).
• Change the type of estrogen used. Women have many individual differences in absorption and metabolism of foods, hormones, vitamins, and medications. Conjugated equine estrogens (Premarin, Prempro) account for about 75–80 percent of the estrogen prescriptions in the United States, yet these products commonly produce less-than-optimal levels of estradiol, have significant variations in absorption due to the enteric coating, and also contain many different chemicals and dyes in this coating that pose a variety of problems for many women with bladder pain.
• If you are taking estrogen and continue to have bladder symptoms of burning, frequency, and urgency, as well as incontinence, then ask your doctor to change the prescription to a form without dyes in the tablet.
• Minimize the amount of estrone relative to estradiol by using transdermal patches of estradiol or by using oral forms that produce less estrone.
• If you have significant urinary difficulties, particularly interstitial cystitis, stress incontinence, and urge incontinence, try a natural human 17-beta estradiol: Estrace or generic estradiol tablets (Alora, Climara, Vivelle and Vivelle DOT) are more effective than the conjugated or esterified estrogens (Premarin, Menest, Estratab, Cenestin) that give you predominately estrone or conjugated estrogens.
• Specialty compounding pharmacies will prepare estriol vaginal creams if you prefer this less-potent form of estrogen, but remember that in general estriol is less effective than estradiol on urinary symptoms. In Europe, low-dose estriol and estradiol vaginal creams have been used successfully for treatment of urogenital problems for women who could not take other types of estrogen. Vaginal forms of these estrogens could theoretically be given without progestin in women who are progestin intolerant.
© Elizabeth Lee Vliet, M.D., 2000
You may ask, “How on earth do I exercise my bladder muscles?” Dr. Arnold Kegel, in 1951, first described the method of muscle exercise to treat incontinence without the drugs or surgery that were the means used by most physicians at that time. The pubococcygeus, or “PC” muscle for short, is the primary muscle of the pelvic floor that governs control of urinary flow and also contracts the vagina (which may intensify pleasurable sensations during intercourse). The PC muscle also supports the uterus, urethra, and rectum. Dr. Kegel was able to show, by means of a device he invented, that the PC muscle could be trained and strengthened with sets of rhythmic contraction-hold-release actions. When the PC muscle is strengthened, it lifts the organs of the pelvis back into their normal positions and enables a woman to better control her urinary flow. Dr. Kegel monitored the strength of muscle contraction with biofeedback so the woman could objectively see how she was doing and learn how to increase her contraction. By 1956, he reported an 86 percent success rate in 455 women with incontinence who had undergone muscle training exercises at his clinic.
Studies since that time have confirmed the marked effectiveness of these methods. The success rate increases significantly if biofeedback techniques are used at the outset to teach women how to isolate the proper muscles and to contract the muscles more effectively. Patricia Burns, R.N., found dramatic improvement in stress incontinence using biofeedback: She reported 50–99 percent decrease in episodes of urine loss. Her research project, conducted at the School of Nursing at the State University of New York at Buffalo, was the first carefully controlled study of behavioral treatments for stress incontinence to show their marked effectiveness. In the biofeedback group, women watched a video screen display of the strength of their pelvic muscle contractions while a nurse trained in the techniques measured those contractions using a vaginal sensor probe. A 1999 study led by Dr. Burgio was published in JAMA, with similar very positive results for biofeedback compared to drug therapy. This is certainly an important option for you to explore in your area to find a specialist using biofeedback. Another technique to strengthen pelvic muscles uses low-intensity electrical stimulation to contract the muscles and progressively strengthen them until the patient can learn how to do it herself. Combining the electrical stimulation with biofeedback has been particularly effective for patients who have not responded to Kegels or biofeedback alone.
Once the techniques are learned correctly, these exercises can be practiced anywhere. Not only that, the behavioral techniques are promising because they don’t involve the risks of surgery or the possible side effects of medicine. You just need motivation, commitment, and practice. If you are having any of the symptoms I have talked about, bring this up with your doctor to find out what resources are available in your area. And before you rush into “bladder tuck” surgery, make sure you have explored the options for strengthening your pelvic muscles nonsurgically. As one woman in her early forties laughingly said, “I practice my Kegels at business meetings, and driving home on the Jersey turnpike, and nobody but me knows what I’m doing. My sex life is great now, and all those embarrassing “leaks” have stopped. And, this way, there’s no expense and no side effects.” Talk about taking charge of your health and regaining your freedom.
Another nonsurgical method of relieving urge incontinence is to follow a timed schedule of voiding, with progressive lengthening of the time interval between urinations. For example, if you find that you are not able to go more than three hours without accidental loss of urine, you would be instructed to urinate every two hours, whether the urge to void is there or not. Each week, you would increase the time between voidings by fifteen to thirty minutes until the bladder is trained to reach your goal for time between urinations. This simple method is also dramatically effective, but it does take your commitment to follow the training schedule. Again, it’s free and there are no side effects.
A novel approach has been developed using the same principles as magnetic resonance imaging. A few centers in the United States have begun trials of a specially designed chair that is attached to a machine generating various frequencies of magnetic fields. A person sits in the chair for a prescribed period of time, with magnetic field therapy directed to the pelvic floor area. I have participated in a demonstration of this device, and although it certainly feels strange to undergo this therapy, the initial clinical studies are promising. I believe that one resource for this therapy is The Center for Pelvic Floor Disorders in Philadelphia, PA, and it may be worth pursuing before you consider more aggressive options such as surgery.
In addition to the benefits of estrogen to improve urinary function, there are other medications that help reduce incontinence. Antispasmodics have been in use for many years and help to reduce bladder muscle spasms that cause urge incontinence. These medications include probanthine, flavoxate, oxybutynin, and imipramine. Alpha-receptor–stimulating medications, such as phenylpropanolamine, help to improve the bladder sphincter muscle tone. A newer medication, Detrol (tolterodine), acts to reduce urinary leakage and incontinence problems by blocking the muscarinic receptors in the urinary bladder. This enables the bladder to hold more urine and increases detrusor pressure, the muscle that keeps the bladder sphincter closed. Detrol may cause dry mouth and dry eyes due to these muscarinic-blocking properties, but generally its side effects are mild. Imipramine is a tricyclic antidepressant, and shares the same side-effect profile I described in earlier chapters for these medications. Briefly, its most bothersome side effects are increased appetite leading to weight gain, dry eyes, dry mouth, constipation, and palpitations. If you are started on one of these medications, you should be properly monitored by a physician to avoid undesirable side effects. Phenylpropanolamine in particular can cause serious high blood pressure emergencies if taken by someone with hypertension and not supervised carefully.
If other methods are not successful, or if there is a specific mechanical repair needed, you may wish to have a consultation with a urologist experienced in the surgical advances for treating incontinence. If you have interstitial cystitis, however, keep in mind that surgical intervention is generally indicated for less than 5 percent of patients. There are a number of new approaches that can be considered, and the specific types of surgery need to be evaluated in the context of your individual needs. Some resources are given in Appendix II to help you locate a specialist in your area. But keep in mind, get your hormone levels tested reliably to see if this is a factor in your problems. If you are trying to decide whether to have surgery for incontinence, it is particularly important to know whether you have optimal estrogen effects (since this is a simpler and less-costly option) before you undergo the pain of surgery and long recovery needed, not to mention a more costly procedure with greater overall risks. See the advice at the end of this chapter from one of my patients who had a long struggle with several surgeries.
If surgery is required, local vaginal application of estrogen is vital to prepare the vaginal and pelvic tissues. Use of intravaginal estrogen preoperatively and postoperatively may often be overlooked and has a number of potential benefits to help improve surgical outcome. Improving the estrogen effect gives the surgeon improved tissue quality with which to work and enhances the success rate of the surgical repair. Continued use of vaginal estrogen cream in the post-operative period further improves wound healing, enhances pain relief, improves formation of healthy connective tissue and mucosa, as well as maintains a healthy pH that minimizes infections.
Dear Dr. Vliet,
I really enjoyed reading your article on the bladder especially the part on incontinence. I do agree with your conclusion that estrogen loss affects incontinence. That has certainly been the case with me. I have lot more leakage when my estrogen level is down. I only wish I had been given this information years ago . . . My stress incontinence began when I was in my late thirties. I would leak when I laughed, coughed, or sneezed. Ten years later it had become a significant problem. I had started to wear a pad every day. I had to leave the golf course on many occasions because I had not just leaked, but had completely wet through my pad and my clothes were soaked. This also happened several times when I had left a restaurant without going to the restroom first. On the way to the car I would leak through the pad and urine would be running down my legs.
I am sure during this ten-year period my estrogen level had dropped tremendously. This thought had never crossed my mind nor was it ever mentioned to me by my gynecologist. All I was ever told was that my bladder had dropped and needed to be suspended. I finally made the decision to do this and two gynecologists told me it would not be effective unless I also had a hysterectomy. So I had both done. Worst mistake ever made. After the surgery I leaked constantly. I have never been given a good answer as to why. Some doctors have said I had a urethra problem not a bladder one. I feel I must have had some muscle or nerve damage during the surgery . . . Since the first surgery I have had fat injections into the urethra by a doctor in New York. Then I had a sling operation by another surgeon. It did not work so I am now having collagen injections. They have helped, but it is temporary because it tends to break down. The estradiol therapy has helped diminish the leakage, and I will try to find someone here to do the biofeedback you suggested. I hope the information in your book can help other women from having to go through what I have been through. Needless to say, the quality of my life has not been good. It has been a very stressful situation as well as very expensive.
“Annie” [not real name]
There has been a great deal of progress in understanding estrogen effects on the bladder, yet we have a ways to go in getting this scientific information from research settings better integrated into the general clinical setting where women are seen for their health care. And there are critical areas needing further study, such as: clarifying the differential response to estrogen therapy based upon type of incontinence, identifying a possible role of testosterone on smooth muscle and connective tissue function in the urogenital system of women, and clarifying beneficial or adverse effects of various progestational medications (including natural progesterone) on IC, vulvodynia, incontinence, and overall urogenital health.
Some changes in bladder function certainly do occur with aging, but keep in mind, there are many new treatments, including natural forms of hormones, that may cure, or certainly improve, these problems. For many women, the various estrogen therapies may lead to significant improvement in bladder symptoms without the need for additional medication or surgery. But these estrogen options are often overlooked or not adequately discussed by doctors, particularly in the elderly postmenopausal woman who may never have used hormone therapy. Dietary change and noninvasive behavioral techniques such as biofeedback and pelvic floor exercises can be combined with various forms of estrogen therapy to achieve synergistic benefit. An integrated approach using multiple modalities is often the most effective way to achieve the greatest degree of improvement. Whatever combined strategies are employed, however, it is important for you to talk with your health professional about whether you could benefit from the use of hormone therapy. Since estrogen has the potential for many additional benefits beyond the urogenital tract, including improved balance, cognition, bone preservation, and cardiovascular function, it is crucial that you at least explore this option rather than continuing to suffer in silence. Being estrogen-complete for postmenopausal women is one of several critical factors to improve and enhance the healthy physiological function of the urinary bladder, urethra, and vagina.
Don’t let embarrassment keep you from asking for help. I really want to encourage all of you reading this book that there is hope, and help, out there in a variety of organizations, physicians, nurse-specialists, and support groups. I have listed some of these resources in Appendix II. Don’t let urinary problems keep you homebound when you have treatment options available.