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Date of release: 19 April, 2010

The menopausal transition stage and incontinence


A recently published paper by Waetjen and colleagues [1] reports on data derived from the SWAN study of community-dwelling, multi-ethnic, mid-life, American women passing through the menopausal transition. A cohort of 1529 women, free of incontinence at baseline, was followed through six annual follow-up visits with a self-administered questionnaire. During that time, 855 women reported some incontinence, with 433 reporting stress incontinence and 244 urge incontinence. Compared with the premenopause, early perimenopause and late perimenopause were associated with an increased risk of ‘monthly or more frequent’ but not ‘weekly or more frequent’ urinary incontinence: relative risks 1.34 (95% confidence interval (CI) 1.07–1.68) and 1.52 (95% CI 1.12–2.05), respectively. In contrast, postmenopausal women experienced no increased incidence of incontinence.


 


The conclusions were that the menopausal transition stage might affect only infrequent incontinence symptoms and that modifiable risk factors for incontinence, such as anxiety, weight gain and diabetes, required more attention and the need to emphasize healthy lifestyle choices.

Comment

The strengths of this study are its size and duration. Its weaknesses include, first, its inability to account for drop-outs, since a higher proportion of women without incontinence at baseline dropped out during the study, and, second, the incontinence questions posed to women in this trial were not from a validated questionnaire.
 
The authors have previously reported on ‘incontinent at baseline’ women in the SWAN study and found no association between menopausal stage and worsening incontinence [2], suggesting that hormonal influences on continence are slight, transient and self-limited. Hormones may influence continence [3] and it has been shown that incontinence is greater in the luteal (estrogen plus progesterone) phase of the menstrual cycle than in the follicular (estrogen-only) phase. A report from the Women’s Health Initiative also showed a weak negative effect of hormone replacement therapy on incontinence [4]. However, other consequences of the menopause transition, such as hot flushes, night sweats, insomnia, urinary frequency and varying vaginal discharge, may also prompt more complaints of mild incontinence and thus potentially confound these findings.
 
In this study, the risk of incontinence worsening on a ‘weekly or more’ frequency did not change with the stage of the menopause transition, although the less frequent category of ‘monthly or more’ did change, but only for total incontinence risk. As independent variables, there was no significant difference in risk of incontinence for early or late perimenopause, postmenopause or stress or urge incontinence and, since the mechanisms for urge and stress incontinence are so different, it seems likely that the small change seen for all-cause incontinence in the perimenopause might be of little clinical significance.
 
Although the link between menopausal stage and incontinence was weak, there were strong associations between incontinence and anxiety and between incontinence and weight gain, both of which significantly increased ‘weekly or more’ incontinence. The association between weight gain and incontinence has been reported previously by others [1, 5, 6]. Diabetes was the strongest risk factor tested for prevalent incontinence. Possible mechanisms for this association include diabetic neuropathy, ischemia, polyuria or concurrent obesity.  
 
The important messages from this study are not that hormones may have a slight effect on continence but that weight gain, obesity, diabetes and anxiety are consistent significant risk factors for developing incontinence, and that healthy lifestyle modifications and treating underlying medical problems may thus help to prevent the majority of incontinence in both perimenopausal and postmenopausal women.

Comentario

Rodney J. Baber
Associate Professor of Obstetrics and Gynaecology at The University of Sydney, Head, Menopause Unit, The Royal North Shore Hospital of Sydney, New South Wales, Australia

    References

  1. Waetjen LE, Ye J, Feng WY, et al. Association between menopausal transition stages and developing urinary incontinence. Obstet Gynecol 2009;114:989-98.
    http://www.ncbi.nlm.nih.gov/pubmed/20168098

  2. Waetjen LE, Feng WY, Ye J, et al. Factors associated with worsening and improving urinary incontinence across the menopausal transition. Obstet Gynecol 2008;111:667-77.
    http://www.ncbi.nlm.nih.gov/pubmed/18310370

  3. Hextall A, Bidmead J, Cardozo L, Hooper R. The impact of the menstrual cycle on urinary symptoms and the results of urodynamic investigation. Br J Obstet Gynaecol 2001;108:1193-6.
    http://www.ncbi.nlm.nih.gov/pubmed/11762662

  4. Hendrix SL, Cochrane BB, Nygaard IE, et al. Effects of estrogen with and without progestin on urinary continence. JAMA 2005;293:935-48.
    http://www.ncbi.nlm.nih.gov/pubmed/15728164

  5. Mishra GD, Hardy R, Cardozo L, Kuh D. Body weight through adult life and risk of urinary incontinence in middle-aged women: results from a British prospective cohort. Int J Obesity 2008;32:1415-22.
    http://www.ncbi.nlm.nih.gov/pubmed/18626483

  6. Ham E, Choi H, Seo JT, et al. Risk factors for female urinary incontinence among middle-aged Korean women. J Womens Health 2009;18:1801-6.
    http://www.ncbi.nlm.nih.gov/pubmed/19951214