Association between menopausal transition stages and developing urinary incontinence

Menopausal stages and overactive bladder symptoms in middle-aged women: A cross-sectional study

OBJECTIVE

To examine the prevalence of overactive bladder (OAB) according to menopausal stages in middle-aged women.

DESIGN

Cross-sectional study.

SETTING

Total Healthcare Center in South Korea.

POPULATION

Middle-aged Korean women (n=3469, mean age, 49.5 ± 2.9 years).

METHODS

Menopausal stages were defined according to the Stages of Reproductive Aging Workshop +10 criteria, and menopausal symptoms were assessed using the Korean version of Menopause-Specific Quality of Life (MENQOL). Logistic regression models were used to estimate prevalence ratios with 95% confidence intervals for OAB according to menopausal stage and to assess the associations with menopausal symptoms.

MAIN OUTCOME MEASURES

OAB symptoms were evaluated using the Overactive Bladder Symptom Score (OABSS).

RESULTS

The prevalence of OAB increased with menopausal stage; however, the multivariable-adjusted prevalence ratios for women in menopausal transition and postmenopausal stage were insignificant (ptrend = 0.160) compared to those for premenopausal women. Among individual OAB symptoms, the multivariable-adjusted prevalence ratios for nocturia increased with menopausal stage in a dose-response manner (ptrend = 0.005 for 1 time/day; ptrend < 0.001 for ≥2 times/day). The association between menopausal stages and nocturia occurring ≥2 times/day was evident in women without OAB and with relatively high MENQOL scores, vasomotor symptoms and difficulty sleeping.

CONCLUSIONS

The prevalence of OAB, particularly nocturia, increased with menopausal stage, and the association was obvious in women with other menopausal symptoms. This finding underscores the importance of addressing nocturia as a potential menopausal symptom in middle-aged women. Further studies are required to understand the mechanisms linking OAB with menopausal symptoms in middle-aged women.

Genitourinary Syndrome of Menopause: Pathophysiology, Clinical Presentation, and Differential Diagnosis

Scientific information is incomplete regarding the genitourinary syndrome of menopause. Both the lower genital and urinary tracts are rich in receptors for reproductive hormones and are highly susceptible to waning ovarian hormones at menopause. Symptoms of dryness and pain emerge in late perimenopause, but they can also result earlier from cancer therapies or bilateral oophorectomy. Lower urinary tract symptoms rise in prevalence at midlife and increase further with advancing age. Because ovarian senescence is typically followed by years of aging, some postmenopausal complaints may be attributable to increasing longevity.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study

INTRODUCTION AND HYPOTHESIS

The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women.

METHODS

Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS).

RESULTS

Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001).

CONCLUSIONS

Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

The female urethra: urethral function throughout a woman's lifetime

INTRODUCTION AND HYPOTHESIS

The objective of this narrative review is to describe changes in urethral function that occur during a woman's lifetime. Evaluation of urethral function includes measurements of urethral closure pressure, at rest and during stress, leak point pressure, and the detailed study of anatomical and histological changes of the urethral sphincteric mechanism.

METHODS

A literature search in MEDLINE, PubMed, and relevant journals from 1960 until 2020 was performed for articles dealing with urethral function and the impact of aging, pregnancy, and childbirth, female hormones, and menopausal transition on the urethral sphincteric mechanism. Longitudinal and cross-sectional epidemiological surveys, studies on histological changes in urethral anatomy during aging, and urodynamic data obtained at different points in a woman's lifetime, during pregnancy, after childbirth, as well as the effects of female hormones on urethral sphincter function are reviewed. Relevant studies presenting objective data are analyzed and briefly summarized.

RESULTS AND CONCLUSIONS

The findings lead one to conclude that a constitutional or genetic predisposition, aging, and senescence are the most prominent etiological factors in the development of urinary incontinence and other pelvic floor disorders. Vaginal childbirth dilates and may damage the compressed pelvic supportive tissues and is invariably associated with a decline in urethral sphincter function. Pregnancy, hormonal alterations, menopausal transition, weight gain, and obesity are at best of secondary influence on the pathology of lower urinary tract dysfunction. The decline of circulating estrogens during menopausal transition may play a role in the transition of fibroblasts to cellular senescence.

Does the climacteric influence the prevalence, incidence and type of urinary incontinence?

Divergent opinions have been reported in the literature regarding the influence of the climacteric on the prevalence, incidence and types of urinary incontinence. In addition, the influence of hormonal therapy in the climacteric (HRT) on the occurrence of urinary incontinence in the perimenopausal period has been the subject of much discussion. This review evaluates the current literature regarding any possible association between the climacteric and the prevalence, incidence and types of urinary incontinence as well as illustrating the possible influence of HRT on urinary incontinence. Urinary incontinence is more common in women than in men and there is evidence to suggest that the prevalence of urinary incontinence in women increases in a linear fashion with age. There is no conclusive evidence to support a specific increase in the prevalence of urinary incontinence at the time of the menopause. Stress urinary incontinence is more common in premenopausal women and urgency urinary incontinence and mixed incontinence are more common in postmenopausal women. Women receiving systemic estrogen, with or without progestogen, are more likely to develop or experience worsening of incontinence.

The role of diet in managing menopausal symptoms: A narrative review

Menopause is a natural stage that occurs when women stop menstruating, during which many women experience physical and psychological symptoms that can affect their quality of life and ability to work. Dietary modifications and food supplements may be explored by some women as alternatives to hormone replacement therapy, although existing reviews and expert position statements have given this limited consideration. This narrative review summarises the current evidence for dietary patterns, and botanical and food supplements, in the management of common menopausal symptoms, including vasomotor symptoms (VMS; hot flushes; night sweats), changes in bodyweight and composition, psychological symptoms (depression; anxiety; cognitive changes), sleep disturbances, joint pain, skin changes and urogenital symptoms. Soy isoflavones may reduce the frequency and/or severity of VMS, although results are inconsistent, and it is unclear whether dietary and supplemental sources have comparable effects. Adopting a healthier dietary pattern may support a healthy bodyweight and benefit VMS. However, evidence suggesting dietary patterns may benefit depression, anxiety, and cognition remains largely observational. While some botanicals, such as black cohosh and St John's Wort, have been reported in some studies to alleviate symptoms (such as VMS and depression), these are not currently recommended due to uncertainty about the appropriate dose and preparation, and potential safety concerns. Evidence for other symptoms is currently too limited to draw conclusions. While further trials at different menopausal stages are needed, adopting a healthier dietary pattern in accordance with dietary guidelines is likely to help support women's health before, during and after the menopausal transition.

Effect of vitamin D supplementation on urinary incontinence in older women: ancillary findings from a randomized trial

BACKGROUND

Observational studies among older women have associated vitamin D insufficiency with a greater prevalence and incidence of urinary incontinence. However, little is known about the effect of vitamin D supplementation in reducing urinary incontinence.

OBJECTIVE

This study aimed to evaluate the effects of vitamin D supplementation in reducing the frequency of urinary incontinence in older women.

STUDY DESIGN

We conducted an ancillary study of women aged ≥55 years in the Vitamin D and Omega-3 Trial, a randomized trial with a 2×2 factorial design. Recruitment of participants started from 2011 to 2014 across 50 US states, and the follow-up of participants ended in January 2018. Randomized treatments in the parent study included (1) vitamin D₃ (cholecalciferol) at a dosage of 2000 IU/d, (2) marine omega-3 fatty acids at a dosage of 1 g/d, and (3) matching placebo. Here, we analyzed women according to their randomization to vitamin D supplementation or placebo, regardless of treatment with omega-3 fatty acid supplementation. Validated frequency of urinary incontinence questions were added in year 2 of the study and were used again in year 5 at the end of trial. Prespecified ancillary outcomes included the prevalence of urinary incontinence at years 2 and 5, along with incident incontinence and progression of incontinence (from lower to higher frequency) from year 2 to year 5. Preplanned subgroup analyses examined the following outcomes: prerandomization of low serum levels of vitamin D (serum 25-hydroxyvitamin D<20 ng/mL), incontinence types, weight categories, and African American race.

RESULTS

Among the randomized women who provided urinary incontinence data, 11,646 women at year 2 and 10,527 women at year 5, the mean age was 70 years at year 2, with 29% racial and ethnic minorities. The prevalence of urinary incontinence that occurred at least weekly was 29% at year 2 and increased to 37% at year 5. Vitamin D supplementation compared to with placebo was not associated with lower odds of urinary incontinence occurring at least weekly at year 2 (odds ratio, 1.08; 95% confidence interval, 0.99-1.19) or year 5 (odds ratio, 1.04; 95% confidence interval, 0.94-1.15). Vitamin D supplementation compared to placebo was not associated with lower incidence or progression of urinary incontinence from year 2 to year 5: incidence (odds ratio, 1.06; 95% confidence interval, 0.83-1.35) or progression (odds ratio, 0.94; 95% confidence interval, 0.82-1.08). Women with prerandomization of low serum levels of vitamin D (n=836) did not have lower odds of the prevalence, incidence, or progression of urinary incontinence. The findings were null in subgroups according to incontinence type, women with obesity, and African American women. Only women with healthy weight randomized to vitamin D had lower odds of progression of urinary incontinence (odds ratio, 0.78; 95% confidence interval, 0.63-0.95; P=.01).

CONCLUSION

Vitamin D supplementation compared to placebo for 2 to 5 years was not associated with differences in the prevalence, incidence, or progression of urinary incontinence in older women with and without adequate serum vitamin D levels, with inconsistent differences among subgroups. The findings showed that the broad use of moderate doses of vitamin D supplementation did not reduce urinary incontinence in older women.

Menopausal status, age at natural menopause and risk of diabetes in China: a 10-year prospective study of 300,000 women

BACKGROUND

Menopause characteristics have been implicated in future health consequences, yet little is known about its relevance to diabetes. We examined the associations of menopausal status and age at natural menopause with diabetes risk in Chinese women.

METHODS

We used prospective data of the China Kadoorie Biobank study that recruited 302,522 women aged 30-79 years in 2004-2008 from 10 areas across China. During average 10.8 years of follow-up, 11,459 incident diabetes cases were recorded among 281,319 women without prior diabetes diagnosis at baseline. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for incident diabetes associated with menopausal status and age at natural menopause.

RESULTS

Overall, the mean (SD) age at natural menopause was 48.2 (4.4) years among 141,789 post-menopausal women. Naturally peri-, or post-menopausal women were at higher risk of diabetes, with HRs of 1.17 (95% CI 1.06-1.29) and 1.15 (1.06-1.25) compared with pre-menopausal women, adjusting for several potential confounders. Among women who had natural menopause, the HR of diabetes was 1.14 (1.01-1.30), 1.01 (0.93-1.09), 1.10 (1.04-1.16), and 1.10 (1.01-1.20) for menopause at ages less than 40, 40-44, 50-53, and 54 years or older, respectively, relative to 45-49 years.

CONCLUSIONS

In this study, we found that women with naturally peri-, or post-menopausal status had higher risk of developing diabetes. Besides, among the post-menopausal women, both earlier and later age at natural menopause were associated with increased risk of diabetes.

[Non-neurological overactive bladder and pelvic-perineal pathology in women]

INTRODUCTION

The aim was to synthesize current knowledge on overactive bladder (OAB) and female pelvic-perineal diseases.

METHOD

A systematic literature review based on PubMed, Embase and Google Scholar was conducted in April 2020.

RESULTS

Women with pelvic organ prolapse very often have OAB. Prolapse surgery should be considered if the prolapse is symptomatic and never be indicated in case of overactive bladder symptoms solely. In case of symptomatic prolapse and OAB, pessary and surgical treatments are effective on both pathologies up to 71 % of the cases. OAB may occur in parallel or as part of a menopausal genitourinary syndrome. In the latter case, only local estrogen therapy is effective. OAB may occur alongside stress urinary incontinence (SUI) or be integrated into mixed urinary incontinence. The initial treatment should be based on the most troublesome symptoms. In case of SUI, the outcome of surgical treatment on OAB remains uncertain. De novo, OAB follows prolapse or SUI surgery. It requires investigations to exclude urinary tract infection, bladder outlet obstruction or erosion. The treatment is the same as OAB.

CONCLUSION

The clinician's challenge is to draw a balance between the OAB and a pelvic-perineal pathology in order to adapt the treatment.

Prediction of Stress Urinary Incontinence Using the Retrovesical (β) Angle in Transperineal Ultrasound

OBJECTIVES

The accurate, rapid diagnosis of stress urinary incontinence (SUI) in women can profoundly improve their sexual and psychosocial life. In this study, the diagnostic power of SUI was assessed by transperineal ultrasound.

METHODS

In this hospital-based case-control study, married women who were referred to the gynecologic and ultrasound wards with negative urinalysis and culture results were enrolled by random sampling. Patients with positive cough signs based on the urodynamic testing data were considered cases, whereas control women showed no cough symptoms and were recruited from the same ward.

RESULTS

There was a significant difference (P < .001) in bladder neck descent (mean ± SD, 10.89 ± 5.51 versus 7.08 ± 2.60 mm, respectively; P = .0001) and the retrovesical (β) angle with the Valsalva maneuver (144.22° ± 19.63° versus 111.81° ± 24.47°; P < .001) between the case and control groups. Also, the β angle without the Valsalva maneuver was higher in the case group (112.35° ± 23.10°) than the control group (120.17° ± 25.16°; P = .001). There was no case of a urinary leak, urethral diverticulitis, a bladder stone or mass, and cystourethrocele in the patients of each group. The results of multivariate logistic regression with a backward method showed that bladder neck descent (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.09-1.40), the β angles with and without the Valsalva maneuver (OR, 1.1; 95% CI, 1.06-1.13; and OR, 1.04; 95% CI, 1.01-1.06) were the predictors of SUI. A β angle higher than 127° with the Valsalva maneuver, with an area under the curve of 0.89 (95% CI, 0.75-0.96), could very well predict the SUI response. This finding shows that it can be very well used to distinguish between normal and non-normal responses, with 89% sensitivity and 79% specificity.

CONCLUSIONS

The β angle with the Valsalva maneuver could very well predict the SUI response.

Identification of Symptom Clusters Among Midlife Menopausal Women with Metabolic Syndrome

The aim of this study was to identify and compare symptom clusters in midlife menopausal women with and without metabolic syndrome based on symptom occurrence and severity dimension through secondary data analysis of the Study of Women's Health Across the Nation. Exploratory factor analysis was used to group symptoms that are highly correlated with each other and verified by confirmatory factor analysis. Midlife menopausal women with metabolic syndrome (n = 424) experienced mental health, vasomotor, and somatic cluster across both symptom dimensions. In contrast, midlife menopausal women without metabolic syndrome (n = 1022) experienced mental health/sleep/urinary, vasomotor, and somatic cluster for symptom occurrence dimension and mental health/sleep, vasomotor/genital, and somatic cluster for symptom severity dimension. This is the first study to identify symptom clusters in midlife menopausal women with metabolic syndrome, who are at risk for experiencing complex symptoms associated with menopause transition and metabolic syndrome, and to compare symptom clusters to those without metabolic syndrome.

Prevention of Urinary Incontinence in Women

PURPOSE OF REVIEW

Despite available treatments for urinary incontinence, the data regarding prevention is less established. This review sought to identify prevention measures and discuss their underlying evidence base with an attempt to include the most recent updates in the field.

RECENT FINDINGS

Urinary incontinence is a prevalent issue among women, particularly surrounding pregnancy and menopause. Interventions regarding pregnancy include not only general health promotion but also potentially interventions such as pelvic floor muscle training and decisions regarding method of delivery. With regard to menopause, the literature suggests avoiding treatments that have adverse effects on continence. Lastly, promoting healthy life style and reducing effects of co-morbid conditions can impact a woman's continence. The literature indicates that preventative strategies exist for urinary incontinence, though the data is limited in this area. Further work is needed to determine the impact of prevention measures and how best to implement them.

Prevalence and Risk Factors of Urinary/Anal Incontinence and Pelvic Organ Prolapse in Healthy Middle-Aged Iranian Women

Objectives

Urinary incontinence (UI) and anal incontinence (AI) cause concern, social exclusion, and ultimately reduced quality of life in women. The aim of present study was to assess the prevalence and related risk factors of UI, AI, and pelvic organ prolapse (POP).

Methods

The present study recruited 340 menopausal women living in Tabriz in northwest Iran. The data collection tools included the Pelvic Floor Distress Inventory-20 and a personal and social information questionnaire. POP was diagnosed via clinical examination using the simplified pelvic organ prolapse quantification system.

Results

The prevalence of UI and POP was approximately 50%, and approximately 16% of participants reported AI. Based on the odds ratios, the most remarkable risk factor of urinary stress incontinence was the number of vaginal deliveries, whereas that of urinary urge incontinence was obesity. Episiotomy and age were the most major risk factors of AI and POP, respectively.

Conclusions

The results of the present study showed that the prevalence of POP, UI, and AI is remarkably high among postmenopausal women, warranting the need to prioritize the assessment of POP and various incontinences in middle-aged women in the primary health care system. Furthermore, increased emphasis should be put on modifiable risk factors.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women

AIMS

Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts.

METHODS

Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span.

RESULTS

Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research.

CONCLUSIONS

This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

Risk factors and prevalence of urinary incontinence in mid-life Singaporean women: the Integrated Women's Health Program

INTRODUCTION AND HYPOTHESIS

The objective was to identify the prevalence and risk factors for urinary incontinence (UI) in healthy midlife Singaporean women.

METHODS

Healthy women, aged 45-69 years, were assessed for UI and sociodemographic characteristics, including ethnicity, menopausal status, parity, and body mass index (BMI). UI subtypes corresponding to stress (SUI) alone, urge (UUI) alone, mixed (MUI), and leakage (drops only) incontinence were classified using the Urinary Distress Inventory 6 (UDI-6). Risk factors were examined using Chi-squared tests, followed by sequential multivariate logistic regression to estimate adjusted odds ratios (aOR and 95% confidence intervals).

RESULTS

A total of 1,119 women (mean age 56.2 ± 5.2) completed the UDI-6. 52.3% reported any UI; MUI and SUI were the most common, each affecting 20% of women. Post-menopausal women had a lower risk (aOR 0.5 [0.3-0.9]) of SUI, but a higher risk (aOR 4.4 [1.0-19.9]) of UUI compared with premenopausal women. Higher education was negatively associated (aOR 0.3 [0.2-0.7]) with UUI, but positively associated with MUI (aOR 2.3 [1.3-4.0]). Parity (1-2 children) increased the risk of SUI (aOR 1.8 [1.0-3.1]), but reduced the risk of UUI (aOR 0.4 [0.2-0.9]). Obesity was associated with increased risk for MUI (aOR 2.2 [1.4-3.4]) and leakage (aOR 2.0 [1.0-4.1]). Malays and Indians had a higher risk of MUI, having (aOR 2.1 (1.2-3.7) and 1.7 (1.1-2.7) respectively compared with Chinese, a difference mediated by higher BMI.

CONCLUSION

Urinary incontinence is a major morbidity prevalent in healthy midlife Asian women. Post-menopausal status, education level, parity, BMI (and its link with ethnicity) are independent risk factors in this population, and should be incorporated into counseling and targeted interventions.

The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Our initial understanding of the menopause transition (MT) has been framed by clinical samples of women seeking treatment rather than by population-based studies. The Study of Women's Health Across the Nation (SWAN) initiated in 1996 with an overall goal to define the MT, to characterize its biological and psychosocial antecedents and sequelae in an ethnically and racially diverse sample of midlife women.

METHODS

This review summarizes the central findings of SWAN to date that can inform women and their healthcare providers about the impact of the MT and midlife aging on overall health and well-being.

RESULTS

SWAN characterized changes in reproductive axis and menstrual cycle patterns that informed the development of the reproductive aging staging system Staging of Reproductive Aging Workshop+10; MT-related symptoms and mental health (vasomotor symptoms, sleep complaints, psychological symptoms, cognitive performance, and urogenital and sexual health); and physiological systems and functions (cardiovascular and cardiometabolic health, bone health, physical function performance) that are influenced by the MT. SWAN demonstrated substantial interrelations among these changes and significant racial/ethnic differences in the rate and magnitude of change in multiple health indictors in midlife women. The findings point to midlife as a critical stage for adopting healthy behavior and preventive strategies.

CONCLUSIONS

Over the past 23 years, SWAN has advanced our understanding of the impact of the MT and midlife aging on health and well-being in women. SWAN will be instrumental to determine whether MT-related changes during midlife are related to unfavorable health and well-being in early old age.

Overweight and obesity as major, modifiable risk factors for urinary incontinence in young to mid-aged women: a systematic review and meta-analysis

The purpose of this review and meta-analysis was to evaluate overweight and obesity as risk factors for urinary incontinence in young to mid-aged women. Understanding these relationships during this life stage is important as early onset increases the risk for developing severe and persistent incontinence. A systematic search resulted in 497 citations, 14 of which were retained for review. Data were analysed by overweight and obesity and by subtype of urinary incontinence - stress, urge, mixed and severe. When compared with 'normal' body mass index, overweight was associated with a one-third increase in risk of urinary incontinence (relative risk = 1.35, 95% confidence interval = 1.20-1.53), while the risk was doubled in women with obesity (relative risk = 1.95, 95% confidence interval = 1.58-2.42). When estimates were pooled according to urinary incontinence subtype, there was no statistical difference in risk. Overweight and obesity are strong predictors of urinary incontinence, with a significantly greater risk observed for obesity. Clinical advice to young women at risk of, or presenting with, obesity should not be limited to metabolic health only but should emphasize the role of excess weight on pelvic floor weakening and subsequent risk of incontinence.

The relationship between menopausal symptoms and sexual function

Sexual function could be affected by several factors in postmenopausal women. This cross-sectional study aimed to investigate the relationship between the severity of menopausal symptoms and sexual function. The study was conducted among 405 postmenopausal women aged 40-65 years, in Chalous and Noshahr, Iran, from October 2013 to May 2014. The participants were selected using a multistage sampling method. The instruments used for data collection were the Female Sexual Function Index (FSFI), the Menopause Rating Scale (MRS), and a demographics questionnaire. The relationship between the severity of menopausal symptoms and sexual function was examined using Pearson's correlation coefficient and multiple linear and logistic regressions. The mean unadjusted FSFI and MRS scores were 24.11 and 12.45, respectively; and 61.0 percent of the participants had female sexual dysfunction (FSD) (FSFI ≤26.55). A significant negative correlation was observed between the MRS scores (total and all subscales) and the total scores for FSFI (p < 0.001). The results of the logistic regression analysis showed that with every unit increase in the total score of MRS, the likelihood of sexual dysfunction was 9.6 percent greater. We conclude that menopausal symptoms need to be considered in the design of health initiatives aimed at postmenopausal women's sexual function.

Symptoms of menopause - global prevalence, physiology and implications

The symptoms of menopause can be distressing, particularly as they occur at a time when women have important roles in society, within the family and at the workplace. Hormonal changes that begin during the menopausal transition affect many biological systems. Accordingly, the signs and symptoms of menopause include central nervous system-related disorders; metabolic, weight, cardiovascular and musculoskeletal changes; urogenital and skin atrophy; and sexual dysfunction. The physiological basis of these manifestations is emerging as complex and related, but not limited to, oestrogen deprivation. Findings generated mainly from longitudinal population studies have shown that ethnic, geographical and individual factors affect symptom prevalence and severity. Moreover, and of great importance to clinical practice, the latest research has highlighted how certain menopausal symptoms can be associated with the onset of other disorders and might therefore serve as predictors of future health risks in postmenopausal women. The goal of this Review is to describe in a timely manner new research findings on the global prevalence and physiology of menopausal symptoms and their impact on future health.

Ten-Year Prevalence and Incidence of Urinary Incontinence in Older Women: A Longitudinal Analysis of the Health and Retirement Study

OBJECTIVES

To measure the incidence of urinary incontinence (UI) over 10 years in older women who did not report UI at baseline in 1998, to estimate the prevalence of female UI according to severity and type, and to explore potential risk factors for development of UI.

DESIGN

Secondary analysis of a prospective cohort.

SETTING

Health and Retirement Study.

PARTICIPANTS

Women participating in the Health and Retirement Study between 1998 and 2008 who did not have UI at baseline (1998).

MEASUREMENTS

UI was defined as an answer of "yes" to the question, "During the last 12 months, have you lost any amount of urine beyond your control?" UI was characterized according to severity (according to the Sandvik Severity Index) and type (according to International Continence Society definitions) at each biennial follow-up between 1998 and 2008.

RESULTS

In 1998, 5,552 women aged 51 to 74 reported no UI. The cumulative incidence of UI in older women was 37.2% (95% confidence interval (CI)=36.0-38.5%). The most common incontinence type at the first report of leakage was mixed UI (49.1%, 95% CI=46.5-51.7%), and women commonly reported their symptoms at first leakage as moderate to severe (46.4%, 95% CI=43.8-49.0%).

CONCLUSION

Development of UI in older women was common and tended to result in mixed type and moderate to severe symptoms.

Factors associated with urinary incontinence in middle-aged women: a population-based household survey

INTRODUCTION AND HYPOTHESIS

The objective was to determine the prevalence of urinary incontinence (UI) and factors associated in a sample of Brazilian middle-aged women.

METHODS

A cross-sectional study was conducted between September 2012 and June 2013 with 749 women. UI was defined as any complaint of involuntary loss of urine. The independent variables were sociodemographic data and health-related habits and problems. Statistical analysis was carried out using Chi-squared test and Poisson regression.

RESULTS

The mean age was 52.5 (±4.4) years. The prevalence of UI was 23.6 %. Of these, 48 (6.4 %) had stress urinary incontinence, 59 (7.8 %) urinary urgency, and 70 (9.5 %) had mixed urinary incontinence. In the final statistical model, self-perception of health as fair/poor/very poor (PR: 1.90; 95 % CI, 1.45-2.49; P < 0.001), ≥1 vaginal deliveries (PR: 1.84; 95 % CI, 1.35-2.50; P < 0.001), higher body mass index (PR: 1.04; 95 % CI, 1.02-1.06; P = 0.001), vaginal dryness (PR: 1.60; 95 % CI, 1.23-2.08; P = 0.001), current or previous hormone therapy (PR: 1.38; 95 % CI, 1.06-1.81; P = 0.019), pre-/perimenopause (PR: 1.42; 95 % CI, 1.06-1.91; P = 0.021), and previous hysterectomy (PR: 1.41; 95 % CI, 1.03-1.92; P = 0.031) were associated with a greater prevalence of UI. Current or previous use of soy products to treat menopausal symptoms was associated with a lower prevalence of UI (PR: 0.43; 95 % CI, 0.24-0.78; P = 0.006).

CONCLUSIONS

Several factors are associated with UI in middle-aged Brazilian women. The results highlight the importance of carrying out interventions aimed at reducing modifiable factors.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.

RESULTS

This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.

CONCLUSIONS

Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

Bladder Symptoms in the Early Menopausal Transition

PURPOSE

Bladder symptoms are common in women and result in use of healthcare resources and poor quality of life. Bladder symptoms have been linked to age and menopause, but debate exists in the literature. This article examines factors associated with bladder symptoms and compares women in late reproductive stage with those in menopausal transition.

MATERIALS AND METHODS

We analyzed cross-sectional data from a prospective cohort study of midlife women (mean age, 48; range, 44-54 years) in northern California. The sample consisted of 158 women in late reproductive stage or menopause transition. Assessments included anthropometrics, menstrual cycle lengths and symptoms, urine samples for follicle-stimulating hormone level, and self-reported health perception and depressive symptoms. Analyses included descriptive bivariate statistics, group comparisons, and regression models.

RESULTS

The most common bladder symptoms were nocturia (72%) at least once per night and urinary incontinence (50%) at least once per week. Incontinence was less prevalent in African American women compared to European Americans and Latinas (p = 0.001) and more prevalent in late reproductive stage than in menopause transition (p = 0.024). Controlling for age, women in late reproductive stage were more likely to report nocturia compared to those in menopause transition. Reproductive stage (p = 0.016), higher body mass index (p = 0.007), and race (p = 0.017) contributed to the variance in weekly nighttime urinary frequency.

CONCLUSION

Bladder symptoms were associated with reproductive stage. Women in late reproductive stage were more likely to experience nocturia and incontinence than those in menopause transition. The higher rates of nocturia and incontinence in late reproductive stage are intriguing. Future studies should include analysis of pelvic organ prolapse degree and other structural differences.

Stress urinary incontinence and endogenous sex steroids in postmenopausal women

AIMS

Urinary incontinence in general is a major cause of quality of life impairment, morbidity and hospitalization. Its onset is strongly linked to the menopause. Our study aimed to elucidate the possible relationship between endogenous circulating estrogens and the onset and development of stress urinary incontinence (SUI).

METHODS

One hundred and thirty eight peri- and postmenopausal women with SUI were matched 1:1 with continent women based on age and BMI. Morning fasting blood samples were drawn from all subjects for assessment of estradiol (E2), FSH, LH, Testosterone, Δ4-Androstendione (Δ4Α), DHEAS, prolactin, SBHG as well as a biochemical profile (glucose, insulin, triglycerides, cholesterol, HDL, LDL, ApoA1, ApoB). Hormone and biochemical parameters were compared between continent and incontinent women.

RESULTS

Incontinent women had significantly lower serum estradiol levels compared to those in the control group (17.30 ± 8.16 vs. 24.22 ± 8.99, P < 0.001). Furthermore, the same association was observed for serum Δ4Α (146.07 ± 52.63 vs. 159.99 ± 42.62, P = 0.017). These associations remained significant after controlling for age, menopausal age, BMI, and number of deliveries.

CONCLUSIONS

These results may indicate that within the postmenopausal range, endogenous sex hormones may be associated with the presence of SUI in women not on menopausal hormone therapy. Neurourol. Urodynam. 36:121-125, 2017. © 2015 Wiley Periodicals, Inc.

Factors associated with seeking treatment for urinary incontinence during the menopausal transition

OBJECTIVE

To examine whether longitudinal urinary incontinence (UI) characteristics, race or ethnicity, socioeconomic status, and education were associated with UI treatment-seeking in a prospective cohort of community-dwelling midlife women.

METHODS

We analyzed data from 9 years of the Study of Women's Health Across the Nation. The study asked participants reporting at least monthly UI about seeking treatment for their UI at baseline and in visit years 7, 8, and 9. Our main covariates included self-reported race or ethnicity, income, level of difficulty paying for basics, and education level. We used multiple logistic regression to examine associations between demographic, psychosocial, and longitudinal UI characteristics and whether women sought UI treatment. We explored interactions by race or ethnicity, socioeconomic status measures, and education level.

RESULTS

A total of 1,550 women (68% of women with UI) reported seeking treatment for UI over the 9 years of this study. In multivariable analyses, women had higher odds of seeking treatment when UI in the year before seeking treatment was more frequent (adjusted odds ratio [OR] 3.16, 95% confidence interval [CI] 1.15-8.67) and more bothersome (adjusted OR 1.09, 95% CI 1.01-1.18), with longer symptom duration, and with worsening UI symptoms (adjusted OR 1.75, 95% CI 1.01-3.04). Women who saw physicians regularly, had more preventive women's health visits, or both were more likely to seek UI treatment (adjusted OR 1.18, 95% CI 1.07, 1.30). Race or ethnicity, socioeconomic measures, and education were not significantly related to seeking treatment for UI.

CONCLUSION

We found no evidence of racial or ethnic, socioeconomic, or education level disparities in UI treatment-seeking. Rather, longitudinal UI characteristics were most strongly associated with treatment-seeking behavior in midlife women.

LEVEL OF EVIDENCE

II.

Affective symptoms and the overactive bladder - a systematic review

BACKGROUND

Overactive bladder syndrome (OAB) is characterised by urgency symptoms, with or without urgency incontinence, usually with frequency and nocturia. Although literature suggest an association between OAB, depression and anxiety, no systematic review has been presented.

OBJECTIVE

Systematically review the literature on the association of affective conditions with OAB.

METHODS

Systematic review according to the PRISMA guidelines. This review is registered in the PROSPERO register (CRD4201400664).

RESULTS

Forty-three articles were included, describing more than 80,000 subjects. Depression and OAB were positively associated in 26 studies, anxiety and OAB in 6 studies. Longitudinal studies reported: a) OAB subjects who developed depression/anxiety or b) depressed/anxious subjects developing OAB, or c) both. The quality of evidence in studies reporting an association between the co-occurrence of OAB and depression was rated level 3 in accordance with the GRADE framework. Evidence reporting on the co-occurrence of anxiety and OAB was rated GRADE level 2. Longitudinal associations between new onset of OAB in depressive subjects was GRADE level 2. Evidence reporting association of OAB with anxiety in longitudinal studies was of GRADE level 1.

CONCLUSION

To our knowledge, this systematic review is the first to give a comprehensive qualitative overview on the association between OAB and affective symptoms. Many evaluated studies failed to note longitudinal changes and lacked evidence of causality. Still, results revealed an association between OAB and affective symptoms and there is evidence for new onset of OAB in depressive subjects, but further research is necessary to examine the strength of the effect.

Incidence and remission of urinary incontinence at midlife: a cohort study

OBJECTIVE

Urinary incontinence (UI) is often considered to be an age-related disease that develops gradually as women grow older. Much remains to be learnt about factors that promote its incidence or its remission. Our objective was to assess its incidence and risk factors.

DESIGN

Longitudinal cohort study.

SETTING

French GAZEL cohort.

POPULATION

A cohort of 4127 middle-aged women (aged 47-52 years at baseline) over an 18-year period (1990-2008).

METHODS

UI was defined as 'difficulty retaining urine'. The question was asked at baseline and repeated every 3 years over an 18-year period. Two groups (UI incidence and remission) were analysed according to status at baseline (continent or incontinent). A multivariable analysis (Cox model) was used to estimate the risk factors for UI incidence and remission.

MAIN OUTCOME MEASURES

Annual incidence and remission rates and risk factors for UI incidence and remission.

RESULTS

The annual incidence and remission rates for UI were 3.3% and 6.2%, respectively. High educational level (hazard ratio [HR] = 1.28; 95% confidence interval [95% CI] = 1.05-1.55), parity, i.e. at least one baby versus no baby (HR = 1.64; 95% CI = 1.19-2.27), menopause (HR = 5.44; 95% CI = 4.47-6.63), weight gain, i.e. for each kilogram change in weight (HR = 1.00; 95% CI = 1.00-1.02), onset of depressive symptoms (HR = 1.31; 95% CI = 1.09-1.57) and impairment in health-related quality of life incidence (social isolation dimension [HR = 1.29; 95% CI = 1.04-1.60] and energy dimension [HR = 1.41; 95% CI = 1.17-1.70]) were associated with an increased probability of UI. The factors associated with persistent UI were age (HR = 0.58; 95% CI = 0.55-0.61), weight gain (HR = 0.99; 95% CI = 0.98-0.99) and transition to menopausal status (HR = 1.54; 95% CI = 1.19-1.99).

CONCLUSIONS

Our study suggests that, in our population of middle-aged women, age, menopause, weight gain, onset of depression and impaired health-related quality of life may promote UI.

Consequences of incontinence for women during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

Although urinary incontinence becomes more prevalent as women age, little is known about the outcomes of urinary incontinence in midlife women. Our aim was to determine the effects of urinary incontinence (stress and urge) on mood (depressed mood, anxiety), perceptions of self (self-esteem, mastery, perceived health), attitudes toward midlife (attitudes toward aging, attitudes toward menopause), and consequences for daily living (interference with relationships, interference with work, sexual desire, physical activity, awakening at night, social support, stress), taking into account the effects of aging

METHODS

A subset of Seattle Midlife Women's Health Study participants (n = 299, with up to 2,206 observations) provided data during the late reproductive stage, early menopausal transition, late menopausal transition, and early postmenopause, including menstrual calendars, annual health questionnaire since 1990, and symptom diaries. Multilevel modeling (R program) was used to test models accounting for urinary incontinence outcomes.

RESULTS

Stress urinary incontinence and urge urinary incontinence were significantly associated with lower self-esteem (P = 0.01 and P = 0.001, respectively) and mastery (P < 0.001, stress urinary incontinence and urge urinary incontinence), with age included in the models as a measure of time. Urinary incontinence's effects on mood symptoms, attitudes toward aging, attitudes toward menopause, perceived health, and consequences for daily living were not significant (P > 0.05).

CONCLUSIONS

Urinary incontinence during the menopausal transition and early postmenopause seems to affect perceptions of self--but not mood, attitudes toward midlife, or consequences for daily living--in this midlife population. Appropriate therapies for urinary incontinence during midlife may promote higher levels of self-esteem and a greater sense of mastery by older women.

Relationship between dietary phytoestrogens and development of urinary incontinence in midlife women

OBJECTIVE

Because exogenous estrogen treatment has been associated with a higher risk of urinary incontinence, our objective was to evaluate the longitudinal relationships of dietary phytoestrogen intakes (isoflavones, coumestans, and lignans) and the development of incontinence in midlife women transitioning through menopause.

METHODS

The Study of Women's Health Across the Nation (SWAN) Phytoestrogen Study was developed within SWAN, a community-based, multisite, multiracial/ethnic, prospective cohort study. SWAN interviewers administered a food consumption assessment at baseline and on follow-up visits 5 and 9. The SWAN Phytoestrogen Study created a phytonutrient database that allowed estimation of the usual daily intakes of four isoflavones, four lignans, and coumestrol. On an annual self-administered questionnaire, participants reported on the frequency and type of incontinence. We used discrete proportional hazards models to evaluate whether the estimated daily intake of each phytoestrogen class on the visit previous to the first report of incontinence was associated with the development of monthly or more incontinence versus remaining continent.

RESULTS

We found no association or patterns of association between developing any, stress, or urge incontinence and the reported daily dietary intake of isoflavones, coumestrol, and lignans on the visit previous to the onset of incontinence.

CONCLUSIONS

The results of this longitudinal study provide important information to better understand estrogenlike substances in the continence mechanism of midlife women. Our study shows that neither high nor low dietary intakes of isoflavones, coumestrol, and lignans prevent stress or urge incontinence. Future studies should evaluate whether serum levels of phytoestrogens or their metabolites impact incontinence symptoms.

Correlates of urinary incontinence during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women's Health Study

BACKGROUND

Urinary incontinence (UI) becomes more prevalent as women age, but little is known about UI in midlife, including stress incontinence (SUI) and urge incontinence (UUI) and their relationship to reproductive aging, reproductive history, health-related factors, and personal and social factors associated with midlife.

OBJECTIVES

To determine the influence of age and reproductive aging factors (menopausal transition stages, follicle stimulating hormone (FSH), estrone glucoronide), reproductive history (number of live births), health-related factors (perceived health, body mass index (BMI), exercise, diabetes) and personal and social factors (race/ethnicity, education) on the experience of UI among midlife women during the menopausal transition and early postmenopause.

METHODS

A subset of the Seattle Midlife Women's Health Study participants (n = 298 with up to 2249 observations) provided data during the late reproductive, early and late menopausal transition stages and early postmenopause, including menstrual calendars, annual health questionnaire and provided health diaries since 1990. Generalized estimating equation analysis was used to test models accounting for SUI and UUI that included age as a measure of time with predictors.

RESULTS

Stress urinary incontinence was associated significantly with individual predictors of: worse perceived health (odds ratio (OR) 0.89, p = 0.025), history of ≥ three live births (OR 3.00, p = 0.002), being in the early menopausal transition stage (OR 1.53, p = 0.06), having less formal education (OR 0.33, p = 0.02), and being White/not Black (OR 0.32, p = 0.04). The most parsimonious model for SUI included: worse perceived health, ≥ three live births, and being White. Urge incontinence was associated significantly with individual predictors of: increasing age (OR 1.06, p = 0.001), worse perceived health (OR 0.78, p < 0.001), BMI ≥ 30 kg/m(2) (OR 2.96, p = 0.001), history of ≥ three live births (OR 2.81, p = 0.01), and lower FSH levels (OR 0.59, p = 0.08). The most parsimonious model for UUI included: being older, having worse perceived health, and having a high BMI.

CONCLUSIONS

SUI risk was a function of reproductive history, poor health, and being White. UUI risk was a function of aging, having worse health, and higher BMI. Further exploration of UI during the menopausal transition is needed to articulate a lifespan view of UI and its typology.

Transobturator suburethral tape in the treatment of stress urinary incontinence: efficacy and quality of life after 5 year follow up

OBJECTIVES

Stress urinary incontinence (SUI) is a highly prevalent dysfunction in middle-aged and elderly women. One recent technique places a sub-urethral tape passed through the transobturator foramen. Efficacy and quality of life were assessed after five years of treatment with the transobturator technique in women suffering SUI. This evaluation followed a previous control at the first year post-intervention.

STUDY DESIGN

Sixty-three women were assessed five years after operation with the transobturator technique. Additionally, twenty-nine women of these women had undergone pelvic floor reconstruction due to different forms of genital prolapse. Quality of life (QoL) was assessed by the Urogenital Distress Inventory-6 (UDI-6) and the Incontinence Impact Questionnaire-7 (IIQ-7) tests.

MAIN OUTCOME MEASURES

Subjective and objective cure or improvement, complications, and changes in QoL.

RESULTS

Fifty women (79%) remained cured, as assessed by the cough test. Eighteen women (28%) reported urine leakage during physical activity. These objective and subjective data were worse than those reported at the one-year follow-up. De novo urge urinary incontinence was reported by 11 women or 17%. Nine of these women had undergone additional pelvic floor surgery. The QoL tests confirmed that cure or improvement was achieved in 78% (49) (UDI-6) and 79% (50) (IIQ-7) of the women.

CONCLUSIONS

The transobturator tape procedure resulted in acceptable rates of efficacy after five years. Moreover, QoL tests showed cure or improvement in almost four of five women. Nonetheless, women should be informed of the risk of de novo urinary urgency incontinence and the progressive loss of efficacy with time.

The epidemiology of urinary incontinence in women with type 2 diabetes

PURPOSE

Little research has been conducted on the epidemiology of urinary incontinence in individuals with type 2 diabetes. We examined prevalence, incidence and risk factors for urinary incontinence among women with type 2 diabetes in the NHS (Nurses' Health Study) and NHS II.

MATERIALS AND METHODS

We obtained urinary incontinence information at study baseline (2000 in NHS and 2001 in NHS II) and 2 followup periods (2002 and 2004 in the NHS, and 2003 and 2005 in the NHS II). Among women with type 2 diabetes we calculated the prevalence of urinary incontinence for 9,994 women with baseline urinary incontinence information, and urinary incontinence incidence rates for 4,331 women with no urinary incontinence at baseline and urinary incontinence information during followup. Multivariable adjusted odds ratios and relative risks were estimated for associations between possible risk factors and urinary incontinence.

RESULTS

The prevalence of at least monthly urinary incontinence was 48% and at least weekly urinary incontinence was 29% among women with type 2 diabetes, and the corresponding incidence rates were 9.1 and 3.4 per 100 person-years, respectively. White race, higher body mass index, higher parity, lower physical activity, current postmenopausal hormone use and diuretic use were risk factors for prevalent and incident urinary incontinence in this study, and hysterectomy, vascular disease and longer duration of diabetes were associated with increased odds of prevalent urinary incontinence only. Increasing age and microvascular complications were associated with a greater risk of frequent urinary incontinence.

CONCLUSIONS

Urinary incontinence was common in this study of women with type 2 diabetes. We identified multiple risk factors for urinary incontinence in these women, several of which suggest ways to reduce urinary incontinence.

Prevalence of stress urinary incontinence in women with multiple sclerosis

Purpose

The purpose of this study was to determine the prevalence of stress urinary incontinence (SUI) in women with multiple sclerosis (MS) and to what degree these women are bothered by their SUI, since there is a paucity of literature regarding the nature of SUI in this unique population of women.

Methods

We conducted a prospective Institutional Review Board approved study. Women scheduled for outpatient follow-up appointments at a dedicated MS center were asked to complete a questionnaire regarding urinary incontinence. Urgency urinary incontinence (UUI) and SUI were defined as an answer of slightly, moderately or greatly to the Urogenital Distress Inventory (UDI-6) question #2 and question #3, respectively. Impact of SUI on physical activity was determined by Incontinence Impact Questionnaire (IIQ-7) question #2.

Results

A total of 55.9% (80/143) women had SUI, 70.6% (101/143) women had UUI, and 44.8% (64/143) women had mixed urinary incontinence. The mean age was 45.8 years old (range, 20 to 72 years). Women with SUI were significantly older (mean, 47.2 vs. 41.9; P=0.023) and there was a trend towards a greater body mass index (mean, 29.3 vs. 26.5; P=0.057). Women with SUI had significantly higher IIQ-7 scores compared to women without SUI (P<0.001). Impact of urinary incontinence on physical activity was also found to be significantly greater in women with SUI (mean IIQ-7 question #2, 0.96 vs. 0.35; P<0.001).

Conclusions

The prevalence of SUI in women with MS is 55.9% and the presence of SUI has a significant impact on their quality of life. A comprehensive urologic evaluation of a woman with MS should include assessment of SUI.

Serum estradiol levels are not associated with urinary incontinence in midlife women transitioning through menopause

OBJECTIVE

We evaluated the relationship between annually measured serum endogenous estradiol and the development or worsening of stress and urge incontinence symptoms during a period of 8 years in women transitioning through menopause.

METHODS

This is a longitudinal analysis of women with incontinence in the Study of Women's Health Across the Nation, a multicenter, multiracial/ethnic prospective cohort study of community-dwelling women transitioning through menopause. At baseline and at each of the eight annual visits, the Study of Women's Health Across the Nation elicited the frequency and type of incontinence using a self-administered questionnaire and drew a blood sample on days 2 to 5 of the menstrual cycle. All endocrine assays were performed using a double-antibody chemiluminescent immunoassay. We analyzed the data using discrete Cox survival models and generalized estimating equations with time-dependent covariates.

RESULTS

Estradiol levels drawn at either the annual visit concurrent with or previous to the first report of incontinence were not associated with the development of any (hazard ratio, 0.99; 95% CI, 0.99-1.01), stress, or urge incontinence in previously continent women. Similarly, estradiol levels were not associated with the worsening of any (odds ratio, 1.00; 95% CI, 0.99-1.01), stress, or urge incontinence in incontinent women. The change in estradiol levels from one year to the next was also not associated with the development (hazard ratio, 0.98; 95% CI, 0.97-1.00) or worsening (odds ratio, 1.03; 95% CI, 0.99-1.05) of incontinence.

CONCLUSIONS

We found that annually measured values and year-to-year changes in endogenous estradiol levels had no effect on the development or worsening of incontinence in women transitioning through menopause.

Etiology of overactive bladder: a diet and lifestyle model for diabetes and obesity in older women

OBJECTIVE

To evaluate a coherent, evidence-based hypothesis that specific modifiable lifestyle factors implicated in the development of diabetes and associated obesity are related to the onset of OAB.

METHODS

A hypothetical causative model for OAB involving modifiable lifestyle factors implicated in the development of diabetes and obesity was constructed, based on a systematic literature review. Secondary analysis of data was undertaken in a prospective cohort of women aged 40 and over, living in Leicestershire, UK. Subjects included 3,411 women free from OAB at baseline and 277 incident cases of OAB. Reported diet, lifestyle, morbid, and social factors were measured at baseline and incident cases at 1-year follow-up. Graphical chain modeling was used to estimate the associations between variables and identify likely pathways involved.

RESULTS

All hypothesized lifestyle factors (physical activity, high glycemic index, and high energy intake) plus diabetes and obesity were retained within the graph as potential contributors. However, low physical activity was the only direct risk factor linked prospectively to the onset of OAB (RR 2.47; 95% CI 1.82, 3.36), in addition to older age.

CONCLUSIONS

Poor lifestyle factors causally linked to diabetes and obesity may contribute to the onset of OAB; low physical activity appears to be an important modifiable causal factor for OAB operating directly as well as indirectly via pathways involving obesity or diabetes. Further research is needed to demonstrate a causal link between lifestyle and OAB.