Menopause Live - IMS Updates

Date of release: 24 November, 2008

Changes in serum estradiol through the menopausal transition and lower urinary tract symptoms

For women, urinary incontinence and other related lower urinary tract symptoms (e.g. nocturia, urinary urgency, frequency) are common, often increasing in frequency as women age. Urinary incontinence, however, is more than just a physiologic loss of urine. Emotional distress is also a significant issue for incontinent individuals. Researchers and clinicians are increasingly aware of the importance of identifying urinary incontinence and, in particular, urinary incontinence that causes distress or adversely affects health-related quality of life in elderly women. A recent article by Gopal and colleagues [1] addresses the association of lower urinary tract symptoms with changes in estradiol levels during the menopausal transition.

In this study [1], a self-administered validated questionnaire to measure lower urinary tract symptoms was administered to 300 premenopausal women as they transitioned to menopause. The association between the change in estradiol levels over time through the menopausal transition and lower urinary tract symptoms (urinary incontinence, filling symptoms, voiding dysfunction) was determined. The authors report that estradiol levels and menopausal stage at one point in time were not associated with lower urinary tract symptoms. Women with a sharp decline in estradiol levels over time had significantly less symptoms in comparison with women without a change in estradiol levels through the study period. Women between the ages of 45 and 49 years had significantly more urinary incontinence symptoms than women older than 55 years. Women with a body mass index greater than 35 also had significantly higher urinary incontinence symptoms than women in the normal weight range, after adjusting for changes of estradiol levels through the menopausal transition. High anxiety was associated with worsening scores in all three lower urinary tract symptom domains (incontinence, filling, voiding). In conclusion, urinary filling symptoms and voiding dysfunction were not associated with changes in estradiol levels through the menopausal transition.


This is an interesting paper, reporting the evaluation of possible effect of menopausal transition on lower urinary tract symptoms [1]. Basically, the results are negative: menopausal transition is not associated with an increase in urinary tract symptoms. This is at variance from other symptoms relevant to women’s health-related quality of life, such as hot flushes, aches, joint pain, stiffness and depressed mood, as reported by the same group of the Penn Ovarian Aging Study [2]. This is a long-term, prospective, cohort study with the aim of assessing the effect of ovarian aging on different aspects of women’s health, from physical activity, stress, risk of breast cancer, sexual function to vasomotor symptoms. The present paper [1] shows that hormonal changes in perimenopausal women are not related to urinary symptoms. There are more than 100 conditions related to urinary tract symptoms, from menopause to cord injury, drugs, exercise, body weight and diabetes. We have good evidence that, in perimenopausal women, lower urinary tract symptoms are definitely associated with parity, body mass index, hysterectomy, diuretic use, stool straining and constipation [3]. These factors, rather than perimenopause itself, are most likely the cause of these symptoms in the 40-60-year age group. This evidence is of importance for the clinician and in particular for the menopause specialist. Often, in the late postmenopausal period, women may experience vaginal dryness, itching, discomfort and dyspareunia. In addition, the atrophic changes caused by estrogen deprivation can cause recurrent lower urinary tract infections, polyuria, dysuria and urgency. Conversely, this paper highlights that the estrogen decline in the short-term period does not affect urinary symptoms in perimenopausal women. Once again, we have to remind ourselves that the climacteric is a period of a woman’s life that lasts more than 30 years, with different characteristics and pathophysiological aspects. Thus, these considerations imply that different management and therapeutic options are required in the different phases of the climacteric.


Marco Gambacciani
Department of Reproductive Medicine and Child Development, Division of Obstetrics & Gynecology ‘P. Fioretti, Pisa University Hospital, Pisa, Italy


  1. Gopal M, Sammel MD, Arya LA, Freeman EW, Lin H, Gracia C. Association of change in estradiol to lower urinary tract symptoms during the menopausal transition. Obstet Gynecol 2008;112:1045-52. Published November 2008.

  2. Freeman EW, Sammel MD, Lin H, et al. Symptoms associated with menopausal transition and reproductive hormones in midlife women. Obstet Gynecol 2007;110:230-40. Published August 2007.

  3. Alling Moller L, Lose G, Jorgensen T. Risk factors for lower urinary tract symptoms in women 40 to 60 years of age. Obstet Gynecol 2000;96:446-51. Published September 2000.