Putting Menopause on the Map

Written By Karine Gulyamova

People who are born a female at birth undergo an aging process such as menopause, marking hormonal changes and, in particular, estradiol levels. Estradiol is the most potent estrogen hormone. It regulates the menstrual cycle and is responsible for the development and maintenance of female sexual characteristics. The skeletal muscle possesses specific estradiol receptors at the fibre levels. Therefore estradiol can promote muscle regeneration and contributing to muscle health.

The loss in estradiol is still believed to be the most important contributor in Menopause and the Loss of Skeletal Muscle.

Genitourinary Syndrome of Menopause (GSM), caused by low estrogen levels affects half of the perimenopausal and postmenopausal women.

The vagina, lower urinary tract, and pelvic floor fibromuscular tissues have the same embryologic origin from the urogenital sinus, and all contain high-affinity estrogen and progesterone receptors.  Estrogen receptors have also been found in endopelvic fascia, levator ani, and uterosacral ligaments. The effects of estrogen deprivation are well documented in the vulva and vagina, with tissue devascularization and decreased collagen genesis. The pelvic floor tissues should similarly undergo neurovascular and connective tissue atrophy in the context of menopause.

The definition of Pelvic Floor Dysfunction (PFD) in females is most often limited to include only urinary incontinence (UI) and pelvic organ prolapse (POP). This fails to acknowledge, however, the role the pelvic floor plays in female sexual function and in other bladder disorders that do not result in incontinence. It also fails to incorporate the unique hormone responsiveness of the pelvic floor. A more comprehensive definition of PFD, at least in menopausal women, should include sexual dysfunction and overactive bladder (OAB) syndrome. The sexual dysfunction of menopause is the result of atrophic change and comprises symptoms including vaginal dryness and dyspareunia. Atrophic change in the lower urinary tract leads to OAB symptoms, dysuria, and recurrent urinary tract infection (UTI).

Estrogen inhibits bladder contractility, so one can speculate that estrogen loss might contribute to OAB symptoms. A loss of periurethral vascularity lowers the urethral closure pressure, in theory contributing to the development of stress incontinence.

In the context of hypovascularity, as the resultant decreased cell turnover decreases the available glycogen these bacteria require for metabolism. The resulting rise in vaginal pH allows colonization of the bladder and vagina with enteric organisms that have long been understood to be a risk factor for UTI.

In the menopause, the most prevalent urogenital symptoms are vaginal dryness (27%), vaginal irritation or itching (18.6%) and vaginal discharge.

Here are a few genitourinary syndromes of menopause that a person might experience:

  • Urinary incontinence:

  • Stress incontinence

  • Urgency incontinence

  • Overactive bladder syndrome

  • Pelvic organ prolapse

  • Pelvic pressure

  • Pelvic/groin/low back pain

  • Voiding difficulty

  • Constipation

  • Difficulty with sexual penetration

  • Vulvovaginal atrophy such as thinning labia,  vaginal dryness

  • Dyspareunia, decreased arousal and/or desire

  • Changes in vaginal pH, effecting microbiome that can result in recurrent UTI

Estrogen stimulates the maturation of the vaginal epithelium and its production of glycogen. Glycogen breaks down to glucose, which in turn is metabolized by vaginal lactobacilli, leading to control of the growth of vaginal pathogens via hydrogen peroxide production . As estrogen levels decrease, there is a loss of lactobacilli, and thus the vagina becomes more alkaline, allowing for colonization of the vagina by fecal fl ora and other pathogens. There is also a change in both quality and quantity of vaginal secretions 6. With estrogen loss, the vagina shortens and narrows due to the loss of elasticity and rugae, and thinning of its walls.

Local vaginal estrogen therapy can provide most women with a more effective and faster relief of genitourinary complaints.

How does estrogen can help with:

  • Decreased symptoms of dryness

  • Decreased feeling of Itching and irritation

  • Lowers vaginal pH and thickens vaginal epithelium

  • Increases rugaue and elasticity

  • Increases vibratory sensations

    Please know that Pelvic Floor PT can help! If you would like to learn more about pre and menopause, join us for a two part series with a panel of experts where we will hold discussions between local doctors, nurses, therapists, dietitians, and strength & conditioning coaches who specialize in women's midlife health on various topics in peri and menopause. Please see more information at https://www.mymenomap.com/

    Meet other people who are seeking new insights and solutions, and know that you are NOT alone on this journey.

Karine Gulyamova