Menopause does more than affect mood swings; it messes with the entire body, even the digestive system. From the mouth to the back end, every part of the gut feels the impact of dropping estrogen levels.
For many women, menopause means changes in digestion, making food less enjoyable and causing tummy troubles. Let’s explore how these shifts can affect bowel symptoms during menopause and why seeking help from the doctor is essential.
The decreasing estrogen levels of menopause affects all the systems of the body and the gastrointestinal system is no different. Right from the mouth to the anus, all parts of the gut are affected by decreasing estrogen levels.
Does menopause worsen irritable bowel syndrome?
Menopause can worsen symptoms of irritable bowel syndrome
As they go through menopause, many women can vouch for the changes in digestion and bowel movement they experience.
- Food they used to enjoy no longer tastes the same and the stomach is not as resilient as it used to be. Food intolerance becomes much more noticeable.
- Dry mouth and burning mouth of menopause is a well-known phenomenon. Digestion of food starts in the mouth and this is compromised because of a decrease in saliva, tooth and gum problems.
- Gut motility changes because of changes in how the sympathetic and parasympathetic system behave in the face of decreasing estrogen levels.
- Stress and lack of sleep at menopause can push cortisol levels up. This affects the microbiome in the gut and the vagina and vulva.
- Gut secretions and behaviour of bowel secretions is altered and irritable bowel syndrome symptoms can worsen because of this.
Bowels symptoms in menopause can cause isolation and depression
Let us look at some symptoms that tend to occur around the time of menopause or get worse as you age.
Fecal urgency
Needing to rush to the toilet to pass stools. This can be worsened in irritable bowel syndrome when the stools are loose and diarrhoea makes holding on to stools much more difficult.
Fecal incontinence
This is the inability to hold on to stool long enough to reach a toilet to pass them. Incontinence may result as a long-term complication of anal sphincter injury at the time of childbirth.
Occasionally it can occur with diarrhea or medication used to relieve constipation. Fecal incontinence can be mild or severe depending upon the cause. If the cause is related to poor sphincter control the leak may only be small amounts noticed on underwear.
However, if it is associated with irritable bowel syndrome and autonomic dyssynergia (imbalance of sympathetic and parasympathetic system) the rectum can end up contracting and emptying its entire contents. This condition is very similar to overactive bladder in its manifestation.
Flatus incontinence
Flatus incontinence is the inability to hold wind. Normally the rectum and anus are very sensitive and have the ability to differentiate between solid and gaseous contents. The higher centers in the brain can control when and where it is appropriate to permit liquid, solid or gas to pass through the sphincter.
If the anal sphincter is damaged during childbirth or nerve damage following pelvic surgery affects the function of the sphincter, flatus incontinence can be the first sign of something not quite right.
Constipation
The other end of the spectrum is constipation. This often occurs for the first time as women go through menopause. The drying effect on gastrointestinal secretions and changing gut microbiome means that food does not get digested as well as before and does not pass through the bowel easily either. Gut motility might slow down worsening the symptom of constipation.
Add to this a weakened pelvic floor and poor rectal sensation – this can cause a delay in emptying the rectum and complicate constipation.
Anal piles and fissures
Chronic constipation and straining at stools can cause piles or haemorrhoids to occur. When the mucosa of the anus is damaged it results in a painful condition called anal fissure. This is much more common in menopause because of the dryness and atrophy that takes place in the genital area.
Anal piles and fissures may respond to medical treatment if diagnosed early. If treatment is delayed surgery may be needed to reduce pain and discomfort.
Management of urogenital symptoms
Urogenital symptoms are very common as you go through menopause. You should not ignore these problems because they rarely go away and usually get worse over time. They often interfere with work, social activities, and sexual and personal relationships. It is important that you seek help from your doctor in time because these problems can be cured, treated or better managed.
Even though you may assume that the menopause is responsible for your symptoms, your doctor will rule out other possible problems too.
I have talked in more detail about how to make the best of your physician consultation towards the end of this article.
History taking
Your doctor will need to take a detailed history of the urinary symptom and how your bladder behaves in different situations. The same is true for bowel related symptoms.
Women are usually much more reluctant to talk about bowel problems, but it is important to discuss them because menopausal changes can affect both bowel and bladder and treatment of one can make the other worse. For example, medications used to treat overactive bladder can cause a dry mouth and constipation. Medication used to treat depression can cause gut motility issues.
Examination and Tests
A physical and pelvic exam comes next. It is normal to perform a cough or stress test when doing a pelvic exam to test for urinary leakage and to check for prolapse. Urine is sent for microscopy and culture to check for infection. The doctor may also do an anal examination if your symptoms include fecal or flatus incontinence or piles and anal fissure.
Additional tests can be asking you to keep a bladder diary, a pelvic ultrasound examination, an Xray of the kidneys and bladder if required, a pad and dye test if suspecting a fistula, cystoscopy and urodynamic studies if surgery is being considered.
For bowel related problems a stool examination and a colonoscopy, anal manometry (measurement of pressure changes in the anus and anal sensation) and a special Xray called a defecography may be needed. Endoanal ultrasound can detect structural damage to the sphincter.
Treatment
Women with bladder or bowel control problems have a wide range of treatment options available to them, based on the type of incontinence and severity. There are many medical and non-medical recommendations for managing these problems. Again, talk with your doctor about which options work best for you.
The International Continence Society Guidelines recommend conservative treatment to start with. This should include pelvic floor physiotherapy, pharmacotherapy and behavioural therapy.
Lifestyle recommendations
Drink at least 1.5 – 2 litres of water to help prevent constipation
- Eat a healthy diet rich in dietary fibre to prevent constipation. We need at least 30gm of fibre each day. Eat at least 2-3 serves of fruit, 5 serves of vegetables and 5 serves of grain, beans or lentils.
- It is important to get the balance right as just adding fibre to your diet without increasing your fluids can cause or make constipation worse. If the steps outlined in this section do not solve an ongoing constipation problem, talk to your doctor.
- Drink water – Drink 1.5 – 2 litres of fluid each day to prevent bladder irritation and constipation, unless otherwise advised by your doctor. Drinking extra fluids is recommended in hot weather or when exercising. Spread your drinks evenly throughout the day. Water is best
- For obese women, losing weight and maintaining a healthy weight may increase bladder control.
- Avoid caffeine, alcohol, carbonated drinks and diuretics that trigger urgency and leakage.
- Improving general physical fitness can be a challenge if stress incontinence is an issue. There are several pessaries and tampons that can be used to support the bladder neck so that exercise need not stop. Keeping fit certainly makes a difference to the management of bladder problems, menopause in general and quality of life.
- Managing fluid intake, alcohol and medications to suit lifestyle so that most bladder activities are completed before bedtime.
- Double voiding – learning to empty the bladder by passing urine twice is very effective at keeping infections at bay.
- Perineal hygiene – learning to keep the vulval area clean and dry. It is important to clean from front to back and to dry the area before putting on underwear. This helps to avoid the bowel bacteria from colonizing the vulva and urethra.
- Neuropathy is a common complication of diabetes mellitus. Nerves to the bladder and bowel can be damaged causing loss of sensation, poor emptying and constipation. Keeping your diabetes well controlled is the best way to prevent or stop nerve damage.
- Practice good toilet habits: Go to the toilet when your bladder feels full or when you get the urge to open your bowels. Do not get into the habit of going ‘just in case’. Take time to completely empty your bladder and bowel.
- Correct toilet position: sit comfortably on the toilet, with elbows on knees, feet on a footstool. It is important to empty the bowel or bladder completely. Avoid ‘hovering’ over the toilet seat because you think it might not be clean if you are using a public toilet. It is better to carry a sanitizer and tissue to clean the seat.
Bladder training
Bladder training helps you to hold on to your urine by gradually increasing the time you hold on before going to the bathroom. Over a period of 4-6 weeks, you can train your bladder to hold more urine for longer by using timed emptying to give yourself a feeling of control.
Local estrogen – does estrogen help menopause bladder symptoms?
The answer is yes!
Vaginal estrogen treatment with creams, tablets, gels or rings is very effective at reducing the symptoms of irritable bladder such as urgency, frequency, nocturia and recurrent urinary infections.
For women who cannot tolerate vaginal estrogen a number of alternative treatments such as vaginal oxytocin gel, laser treatments and oral ospemifene have been suggested.
There is not enough data to suggest whether vaginal estrogen therapy is useful in the management of fecal incontinence.
Hormone Replacement Therapy
As lack of estrogen is the primary cause of urogenital atrophy, the treatments for it in postmenopausal women involve low-dose hormone replacement therapy (HRT). These can help restore the vagina to premenopausal condition and relieve many symptoms of urogenital atrophy. If systemic estrogen therapy doesn’t improve bladder function, additional vaginal estrogen is sometimes prescribed.
There are newer medications like Bazedoxifene and Ospemifene that have been trialed.
Prescription medication
Anticholinergic medication is used to decrease overactive bladder symptoms (Tolterodine, oxybutynin, solifenacin, darifenacin, mirabegron). Drugs like Duloxetine are used to manage mild symptoms of stress incontinence. Drugs like alpha blockers are often used in women who have a narrowed urethra and need to strain to pass urine.
Antibiotics may be required to treat recurrent urinary tract infections in addition to managing the voiding problems and prolapse which may be the real reason why the infections keep happening.
Drugs used to treat overactive bladder can worsen dry mouth and constipation. It is worth keeping a diary of symptoms to report back to your doctor with the side effects of medication you are taking.
Pelvic floor exercises and pelvic floor physiotherapy
Pelvic floor exercises can strengthen the pelvic floor reducing the risk of uterovaginal prolapse and improving symptoms of urinary leakage. Many women have learnt these techniques from childbirth, but it is well worth revisiting them.
Pelvic floor physiotherapy is the first line therapy for both stress urinary incontinence and urge incontinence and makes a significant difference to treatment outcomes even if you need medication or surgery.
Pelvic-floor physiotherapists are specialists with expertise in assessing pelvic floor function involved in continence – both urinary and bowel. They are able to assess and monitor a woman’s pelvic floor function and teach appropriate techniques to strengthen it and retrain the bladder. They often use devices to help women perform appropriate exercises, such as weighted vaginal cones, or vaginal trainers, biofeedback machines and electrical stimulation if pelvic floor muscle tone is poor.
Medical devices
A pessary is often inserted into the vagina to support the bladder neck or also to support a prolapsed uterus. The pelvic floor needs to have good enough tone for pessaries to work effectively.
Nerve stimulation devices
Sacral neuromodulation is a treatment used in cases of overactive bladder which have not responded to other conservative measures
Botox
Botox injections into the bladder wall help to relax it over a period of 6-8 weeks. In patients with overactive bladder this can either completely relieve symptoms or allow sufficient time for bladder retraining to become an established habit which can relax the bladder muscles.
Surgery
If surgery is required to treat stress urinary incontinence (sling surgery or colposuspension) or surgery to treat a fistula, a more detailed assessment with a computerised test called urodynamics is performed. This gives a better idea of the likelihood of success of surgery and the possibility of side effects or disadvantages. Much of this surgery is now done with minimally invasive techniques using endoscopy.
Piles or hemorrhoids and anal fissures may need surgery if they do not respond to medical treatment (usually local anesthetics, antibiotics and stool softeners).
Discussing bladder and bowel problems with your doctor…
How to talk to your doctor about urogenital symptoms in menopause?
Most women, even doctors, feel embarrassed to talk about intimate problems relating to the bladder bowel or sex. It is easy to turn up to your appointment unprepared and miss out important subjects that need attention. This is particularly important because bowel and bladder problems that arise at the time of the menopause do not get better – rather they tend to get worse with age. The earlier you get diagnosed and treated the better it is for your overall health and quality of life.
Here are some tips for discussing “embarrassing” problems with your physician:
- Make a list of what you want to discuss and how the problem affects you
- Discuss the most important or most difficult questions first. You may find that your doctor is only willing to discuss the first point on your list due to time restrictions. Make sure the first point is the most important or the one that causes you most distress.
- Take someone with you that can write down what the doctor says or listen to important points for you.
- Write down what the doctor tells you
- If there is anything that you don’t understand, ask for clarification
- If you doubt being able to put your problem into words take some printed material with you. This could be a magazine article or information from a website on the internet.
- If you feel embarrassed, practice talking to your doctor in front of a mirror or do a role play with a friend. Repeat 3-4 sentences till you feel comfortable saying them.
- If you still feel unable to discuss the subject, write it all down and hand it to the doctor
- Make a list of details you want the doctor to know and give it to the doctor. This can include your symptoms, the effect it has on your quality of life, other illnesses, medication you are currently taking, any other over the counter medications or alternative treatments you have tried and whether they worked or not.
Conclusion
Urogenital symptoms in menopause can significantly affect quality of life. Majority of the problems relating to bladder, bowel and vaginal dryness are not life threatening but they can seriously affect everyday activities of living.
Almost 65% of women over the age of 60 years will suffer with bowel and bladder problems related to the menopause and decreasing estrogen levels. Less than 25% will seek help for these and less than 40% get the treatment they need. This happens even though effective treatment is available for all genitourinary problems and they can be treated or managed so that they do not affect everyday life adversely or deteriorate with time.
Most women are embarrassed to speak to their doctor about their problems and this delay in diagnosis and treatment can cause the problem to deteriorate significantly. If caught early, treatment is simple and can even cure the problem.
If any symptoms in this article have caused you to think about your own bladder and bowel symptoms or symptoms of vaginal dryness, I would encourage you to write them down and book an appointment to see your doctor as soon as you can. Take the tips above into consideration when you get your appointment.
Do write to me at masterthemenopause@gmail.com about what you liked in this article and whether it helped you address some of your concerns.
Look out for more content related to topics in this article as I will be diving deeper into them in future posts.
References
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Dumoulin C, Hay-Smith J. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD005654. DOI:
Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Herderschee R, Hay-Smith EJC, Herbison GP, Roovers JP, HeinemanMJ. Cochrane Database of Systematic Reviews 2011, Issue 7. Art.No.: CD009252. DOI:10.1002/14651858.CD009252.
Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Chantale Dumoulin 1, Licia P Cacciari, E Jean C Hay-Smith Cochrane Database Syst Rev. 2018 Oct 4;10(10):CD005654. doi: 10.1002/14651858.CD005654.pub4. https://pubmed.ncbi.nlm.nih.gov/30288727/
Do fluctuations in ovarian hormones affect gastrointestinal symptoms in women with irritable bowel syndrome? Margaret M Heitkemper 1, Lin Chang Gend Med. 2009;6 Suppl 2(Suppl 2):152-67.doi: 10.1016/j.genm.2009.03.004. https://pubmed.ncbi.nlm.nih.gov/19406367/Effect of oestrogen therapy on faecal incontinence in postmenopausal women: a systematic review. Bach, F.L., Sairally, B.Z.F. & Latthe, P. Int Urogynecol J 31, 1289–1297 (2020). https://doi.org/10.1007/s00192-020-04252-1