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

Genitourinary Syndrome of Menopause: Prevalence and Predictors

The genitourinary syndrome of menopause (GSM) has been proposed as a diagnosis by a consensus of clinicians and investigators. Our purpose for this paper is to review extant evidence about: 1) the breadth of symptoms and symptom clusters as related to the syndrome; 2) the prevalence of GSM (includes vulvar and vaginal atrophy); 3) factors that are associated with, predict, or explain the syndrome; and 4) what should be pursued for expanding meaningful evidence. Within recent literature, we found a wide range of prevalence estimates, likely a function of the differing populations studied, study design, and methods of data collection. Factors related to the prevalence of GSM included age and aging; reproductive aging stage; hormones, especially estrogen; and culture and language. We recommend further specification of diagnostic criteria for GSM; clarification of urinary symptoms in GSM; use of longitudinal study designs; validation of GSM-related measures; exploration of cultural equivalence of GSM measures; and assessing biases in completed research.

Association of overweight, obesity and risk of urinary incontinence in middle-aged and older women: a meta epidemiology study

Aims

The aim of this meta-analysis is to evaluate the potential correlation between obesity and overweight, and the vulnerability to urinary incontinence (UI) in women aged middle-aged and above.

Methods

We searched PubMed, Cochrane Library, and Embase for observational studies published between the inception of the databases and April 25, 2023. A fixed-effects model was used when the P>0.1 and the I2 ≤ 50%. In cases where I2 ≥ 50% (indicating significant heterogeneity), a random-effects model was applied. For the purpose of evaluating publication bias, a funnel plot and Egger's test were used. Stata 14.0 was used for all statistical analyses.

Findings

This meta-analysis includes 16 observational studies, covering29,618 individuals. The pooled analysis shows that being overweight(25 kg/m2≤BMI<30kg/m2) in middle-aged and elderly women is more likely to develop UI (OR=1.27; 95% CI: 1.17-1.37; I2 = 51.8%, P=0.013). Middle-aged and elderly women with obesity(30 kg/m2≤BMI<35 kg/m2) are significantly more likely to develop UI (OR=1.60; 95% CI: 1.42-1.81; I2 = 71.8%, P=0.000). In addition, the results indicated a higher probability of UI in middle-aged and older women with obesity class II (BMI≥35 kg/m2) (OR=1.85; 95% CI: 1.59-2.16; I2 = 48.1%, P=0.103). In subgroup analysis, there is no direct relationship between the obesity in middle-aged and elderly women and an increased risk of stress urinary incontinence (SUI) (OR=1.31; 95% CI: 0.99-1.74; I2 = 63.7%, P=0.011). In middle-aged and elderly women with obesity are more likely to develop urgent urinary incontinence (UUI) (OR=2.11; 95% CI: 1.54-2.89; I2 = 80.2%, P=0.000).

Conclusion

In this meta-analysis, overweight and obesity are associated with an increased risk of UI in middle-aged and elderly women. Obesity and overweight are independent risk factors for UI, as demonstrated by this study.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023421986.

Childhood Sexual Abuse and Pelvic Floor Dysfunction in Midlife Women in the Study of Women's Health Across the Nation

Objectives: Research has shown a link between childhood sexual abuse (CSA) and lower urinary tract and sexual disorders in clinical settings. We examined whether CSA was associated with two specific aspects of high tone, elevated resting tension pelvic floor dysfunction (PFD) in community-dwelling women. Materials and Methods: Data were from 2068 participants (25.5% Black, 9.6% Chinese, 10.8% Japanese, 5.0% Hispanic, and 49.1% Non-Hispanic White) in the Study of Women's Health Across the Nation (SWAN), a multirace/multiethnic longitudinal observational study of women's midlife health. At baseline, enrolled women were 42-52 years old and premenopausal or early perimenopausal. Annual or biennial assessments conducted over 20 years (1996 through 2017) included single-item queries about urgency urinary incontinence and pain with sexual activity used to assess PFD outcomes. The 12th follow-up visit conducted in 2009-2011 assessed the primary exposure, history of CSA, using a single-item response. Multivariate logistic regression models tested study objectives. Results: The prevalence of CSA was 15%, self-reported in 313/2068 women. CSA and PFD, both pain with sexual activity (odds ratio [OR] = 1.56 confidence interval [95% CI = 1.12-2.18]) and urgency urinary incontinence (OR = 1.87 [95% CI = 1.29-2.71]), were significantly associated in unadjusted models. The final adjusted model that included sociodemographic variables and physical and behavioral risk factors was significant for pain with sexual activity (OR = 1.48 [95% CI = 1.08-2.02]), but not for urgency urinary incontinence (OR = 1.38 [95% CI = 0.96-1.98]). Conclusions: In midlife women, pain with sex, but not urgency urinary incontinence, was associated with a history of CSA. A multidisciplinary diagnostic and therapeutic approach to PFD is key, inclusive of CSA screening.

Perimenopause meets life: observations from the Women Living Better Survey

OBJECTIVE

The purpose of these analyses was to test a predictive quantitative model relating personal characteristics, reproductive aging stages, health behaviors, roles, stressors, and satisfaction with life roles to bothersome symptoms experienced during the late reproductive stage and the menopausal transition (MT).

METHODS

Participants (N = 2,406) aged 35 to 55 years completed the Women Living Better Survey online between March to August 2020, and 1,529 met the inclusion criteria and provided menstrual cycle data for staging reproductive aging. They were recruited from the Women Living Better newsletter and from other online groups of midlife women. Hierarchical regression analysis using a two-stage model tested the effect of several factors on each of five bothersome symptom groups: brain fog, volatile mood, fatigue/pain, vasomotor/sleep disruption, and anxiety/vigilance symptoms. In stage I, personal characteristics, reproductive aging stage, and health behaviors were examined, and in stage II roles (ie, caregiver, partner, employment-related), satisfaction with life roles and stressors associated with roles were added.

RESULTS

More bothersome brain fog symptoms were associated with less education, MT (vs late reproductive stage), low satisfaction with life roles, and greater health-related and overcommitment stress (all P < 0.005). More bothersome volatile mood symptoms were associated with health-related, partner relationship, and other relationship stress. More bothersome fatigue/pain symptoms were associated with less education and greater difficulty paying for basics and health-related and other relationship stress. Vasomotor/sleep-onset symptoms were associated with less education, MT, and health-related and work stress. More bothersome anxiety/vigilance symptoms were associated with less education, more difficulty paying for basics, and health and work stress.

CONCLUSIONS

Recognizing that midlife stress comes from many role- and relationship-related sources and that several of these stressors are associated with greater symptom bother supports the importance of proactive identification and management of sources of stress.

Symptom experience during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey

OBJECTIVE

The aim of this study was to examine the occurrence of a variety of symptoms, their frequency, bother, burden, and interference in the lives of women in the late reproductive stage (LRS) and compare their experiences to that of women in the menopausal transition (MT) stage.

METHODS

Women ages 35 to 55 years responded to an 82-question online survey offered by Women Living Better. Participants reported current menstrual patterns, recent changes and symptom frequency, bother, and interference. Women's cycles were classified as LRS or MT using Stages of Reproductive Aging Workshop +10 criteria.

RESULTS

Of 2,406 respondents, 946 met criteria for LRS and 583 for MT. Participants included 30% from outside the United States, 31% from diverse racial/ethnic groups, and 18% reported having difficulty paying for basics. A similar proportion of women in the LRS and MT+ groups reported each of the symptoms: there was a less than 10% difference for 54 of the 61 symptoms. Of mean bother ratings for all symptoms, only hot flashes differed significantly between the LRS and MT groups. LRS women experienced similar levels of symptom-related interference with personal relationships and daily living to those in the MT stage but did not anticipate these symptoms occurring until they were 50 years old.

CONCLUSIONS

Women in the LRS experience symptoms strikingly similar to those often associated with the MT. Women do not expect these changes until the age of 50 years or later and are surprised by such symptoms before cycle irregularity. Research about the epidemiology and management of LRS symptoms, anticipatory guidance for women, and education for clinicians who care for them warrant increased attention.

"You're acting womanish!" A qualitative descriptive study of the experiences of African American women in menopausal transition

This study explores how African American women understand and experience menopausal transition. Data were collected from 14 women in individual interviews and a focus group of seven participants. Transcripts were analyzed using content analysis. Black Feminist Thought and Womanist Thought were the frameworks used to understand the experiences of participants. Key themes emerged including silence as a form of survival, resilience amidst the chaos, socialization for self-preservation and empowerment, and reshaping and reclaiming womanhood. African American women need to be approached from a culturally sensitive care model to address their care during this phase and to optimize health outcomes.

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.

Adulthood transitions in health and welfare; a literature review

AIM

The aim of the literature review was to describe how adulthood transition is used in health and welfare.

DESIGN

A qualitative design with a deductive approach were used.

METHODS

As material, 283 articles published in scientific journals, between 2011-August 2013, were selected. The search was conducted August 2013. The data were analysed and sorted in a categorization matrix.

RESULTS

Transition was identified as a process mainly related to the four types previously identified; developmental, situational, health-illness and organizational transitions. Another one transition was also identified, lifestyle transition.

Effects of multiple simulated birth traumas on urethral continence function in rats

Multiple vaginal parities have been reported to be an important risk factor for stress urinary incontinence (SUI). Simulated birth trauma with single vaginal distention (VD) has been used to induce the SUI condition in animals; however, the effect of multiple simulated birth traumas on the urethral continence function has not been well characterized. Therefore, we examined the effects of multiple VDs on urethral functions in vivo and the changes in gene expressions of several molecules in the urethra using female SD rats, which were divided into three groups; sham, VD-1 (single VD), and VD-3 groups (3 times of VDs every 2 wk). Two weeks after the final VD, leak point pressure (LPP) and urethral responses during sneezing were evaluated. Also, changes in mRNA levels of urethral molecules were quantified with RT-PCR.　The VD-1 group did not show any change in LPP with only a tendency of decrease in amplitudes of the urethral responses during sneezing (A-URS); however, the VD-3 group showed a significant decrease in LPP and urethral responses such as baseline urethral pressure and A-URS accompanied with SUI episodes during sneezing. Nicotinic receptor subtypes and transforming growth factor (TGF)-β1 were significantly increased in both VD-1 and VD-3 groups while TNF receptor (TNFR)-1, IL-6, collagens, and matrix metalloproteinases-9 were significantly increased only in the VD-3 group.　These data indicate that rats with multiple simulated birth traumas exhibit profound impairment of the urethral continence function and that these functional changes are associated with those in cytokines, extracellular matrix molecules, and nicotinic receptor subtypes in the urethra.

Urinary incontinence in women

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Micturition dysfunction in four-month old ovariectomized rats: Effects of testosterone replacement

AIMS

Androgen deficiency has been implicated in urological complications of postmenopausal women. This study examined the effects of testosterone replacements on the lower urinary tract dysfunction in 4-month old ovariectomized (OVX) rats.

MAIN METHODS

Sprague-Dawley female rats were OVX bilaterally. Three months later, rats received single intramuscular injections of testosterone undecanoate. Cystometric study, and bladder and urethra smooth muscle reactivities were evaluated.

KEY FINDINGS

Ovariectomy reduced by 65% (p<0.05) the serum testosterone levels. Testosterone replacement at 5mg/kg restored serum hormone levels to baseline, whereas 10mg/kg produced 14-fold higher testosterone levels. OVX rats exhibited significant increases of body weight, perigonadal fat and blood pressure, and reduced uterus weight, but none of these parameters were changed by testosterone replacements. OVX rats exhibited micturition dysfunction characterized by increases of basal pressure, threshold pressure, voiding frequency and post-voiding pressure. In addition, the bladder contractions induced by electrical-field stimulation (EFS) and carbachol were significantly reduced, whereas angiotensin II-induced urethral contractions were significantly increased in OVX rats. Testosterone replacement at 10mg/kg (but not at 5mg/kg) dose fully normalized the in vivo micturition dysfunction, as well as the in vitro bladder and urethral alterations. Testosterone (10mg/kg) also significantly potentiated the bladder relaxations induced by the β₃-adrenoceptor agonist mirabegron. The protective effects of testosterone were not modified by concomitant treatment with the aromatase inhibitor letrozole (2.5mg/kg, 4weeks).

SIGNIFICANCE

The improvement of micturition dysfunction by testosterone replacement suggests that androgen therapy might be of therapeutic benefit for urological complications associated with post-menopause.

The Seattle Midlife Women's Health Study: a longitudinal prospective study of women during the menopausal transition and early postmenopause

Background

The need for longitudinal, population-based studies to illuminate women’s experiences of symptoms during the menopausal transition motivated the development of the Seattle Midlife Women’s Health Study.

Methods

Longitudinal, population-based study of symptoms women experienced between the Late Reproductive stage of reproductive aging and the early postmenopause. Data collection began in 1990 with 508 women ages 35–55 and continued to 2013. Entry criteria included age, at least one period in past 12 months, uterus intact and at least 1 ovary. Women were studied up to 5 years postmenopause. Data collection included yearly health questionnaires, health diaries, urinary hormonal assays, menstrual calendars and buccal cell smears.

Results

Contributions of the study included development of a method for staging the menopausal transition; development of bleeding criteria to differentiate bleeding episodes from intermenstrual bleeding from menstrual calendars; identification of hormonal changes associated with menopausal transition stages; assessment of the effects of menopausal transition factors, aging, stress-related factors, health factors, social factors on symptoms, particularly hot flashes, depressed mood, pain, cognitive, sexual desire, and sleep disruption symptoms, and urinary incontinence symptoms; identification of naturally occurring clusters of symptoms women experienced during the menopausal transition and early postmenopause; and assessment of gene polymorphisms associated with events such as onset of the early and late menopausal transition stages and symptoms.

Conclusions

Over the course of the longitudinal Seattle Midlife Women's Health Study, investigators contributed to understanding of symptoms women experience during the menopausal transition and early postmenopause as well as methods of staging reproductive aging.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0019-x) contains supplementary material, which is available to authorized users.

Epidemiological trends and future care needs for pelvic floor disorders

PURPOSE OF REVIEW

We sought to provide a review of the recent literature regarding the prevalence and epidemiological trends in pelvic floor disorders (PFDs) including pelvic organ prolapse (POP), urinary incontinence and fecal incontinence. We also examined the current trends in surgical treatment for these disorders and discuss future care needs.

RECENT FINDINGS

Approximately, one quarter of all women suffer from at least one or more PFDs. Urinary incontinence represents the most common PFD with an estimated prevalence of 15-17%, whereas fecal incontinence affects, approximately, 9% of adult women. POP is more difficult to assess with prevalence estimates ranging from 3 to 8%. Surgery for PFDs is common as 20% of women undergo stress urinary incontinence or POP surgery over their lifetime. As the aging population grows, the number of women with PFDs will increase substantially and the demand for care for these disorders will continue to grow through the year 2050.

SUMMARY

PFDs are a significant public health issue and they negatively impact the lives of millions of adult women. The projected increase in the number of women affected by PFDs over the next 40 years will create increased demand for providers properly trained in Female Pelvic Medicine and Reconstructive Surgery.

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.

Evidence-Based Practice in the United States: Challenges, Progress, and Future Directions

Scientific literature demonstrates that advances in evidence-based nursing have improved systems of care and women's health outcomes. Experts agree that nurses worldwide can play a key role in building such evidence and working with interdisciplinary health care teams and systems to accelerate its implementation.