Posts Tagged ‘menopause’

Menopause: Impact on Nether Regions

September 23, 2017

Andrew Siegel MD  9/23/17

Symptoms_of_menopause_(raster)

Image above by Mikael Häggström (Own work) [CC0], via Wikimedia Commons

Menopause is the cessation of estrogen production by the ovaries.  It typically occurs at about age 51-years-old, so most women can expect to live another thirty or more years following this event. Many bodily changes occur with menopause, with the urinary and genital systems undergoing sudden and, at times, dramatic changes due to the absence of estrogen stimulation.

The constellation of symptoms related to menopause used to be referred to as “atrophic vaginitis” or “vulvo-vaginal atrophy.” However, these terms were considered disparaging, hurtful and cruel, especially the words “atrophic” and “atrophy,” which imply wasting away through lack of nourishment. Also, the “-itis” designation incorrectly implied inflammation or infection. A more politically correct, medically accurate, less embarrassing and more acceptable term was proposed by the International Society for the Study of Women’s Sexual Health and the North American Menopause Society: “Genitourinary Syndrome of Menopause (GSM).”

“Genitourinary Syndrome of Menopause”–  I don’t particularly care for this term because of its length, the fact that it sounds way too clinical, and implication that menopause causes a medical “syndrome” or “disease” as opposed to a natural, physiological, age-appropriate, virtually universal situation.  Why not label the constellation of symptoms related to menopause as “menopausal symptoms and signs”?

The female hormone (estrogen)-stimulated vagina of a young adult female has a very different appearance from that of a female after menopause. The vestibule, vagina, urethra and base of the urinary bladder have abundant estrogen receptors that are no longer stimulated after menopause, resulting in diminished tissue elasticity and integrity.  Age-related changes of the vulva and vagina can lead to dry, thinned and brittle tissues with loss of vaginal length and width, lubrication potential and expansive ability. Considering that nature’s ultimate purpose of sex is for reproduction, perhaps it is not surprising that when the body is no longer capable of producing offspring, changes occur that affect the anatomy and function of the genital organs.

Symptoms and Signs of Menopause

General

  • Hot flashes
  • Night sweats
  • Sleep disturbances
  • Mood changes and fluctuations

Vulva

  • Thinning/loss of elasticity of labia and underlying fatty tissues
  • Diminished tissue sensitivity
  • Paler, thinner and more fragile vulvar skin
  • Increase in vulvar skin issues and vulvar pain, burning, itching and irritation

 Vagina

  • Thinning of the vaginal wall
  • Loss of vaginal ruffles and ridges
  • Shortened vaginal dimensions
  • Looseness of  the vaginal opening
  • Increased vaginal pH (less acid environment)
  • Increased vaginal colonization by colon bacteria and more frequent vaginal infections

 Sexual

  • Diminished sex drive
  • Vaginal dryness
  • Diminished arousal
  • Diminished lubrication
  • Diminished ability to achieve orgasm
  • Tendency for painful sexual intercourse

 Urinary 

  • Thinning of the urethral wall and tissues adjacent to the urethra
  • Urinary infections: Before menopause, healthy bacteria reside in the vagina; after menopause, the vaginal bacterial ecosystem changes to colon bacteria, which can predispose to infections.
  • Overactive bladder symptoms: urinary urgency, frequency, urgency incontinence
  • Stress urinary incontinence (urinary leakage with sneezing, coughing, exercise and exertion)
  • Urethral caruncles (benign fleshy outgrowths at the urethral opening)

What to do?

If the symptoms and signs of menopause are not bothersome, nothing need be done. In fact, many women relish not having menstrual periods and tolerate menopause uneventfully.  However, if one’s quality of life is adversely affected, consideration can be made for hormone replacement therapy, particularly if the menopausal symptoms are disruptive and debilitating.

Hormone Replacement

Systemic hormone therapy is available in the form of pills, skin patches, sprays, creams and gels. It can be effective in managing bothersome menopausal symptoms when used for the short-term. Estrogen alone is used in women who have had a hysterectomy, whereas estrogen and progesterone in those who have a uterus. The potential side effects of systemic therapy include an increased risk for heart disease, breast cancer and stroke.

Vaginal hormone therapy is available in creams, rings and tablets. The advantage of  locally-applied estrogen is that it can help manage menopausal pelvic floor issues with minimal absorption into the body and minimal potential systemic effects, as would be expected from oral hormone replacement therapy. It can be helpful for painful intercourse, overactive bladder, stress urinary incontinence, pelvic organ prolapse and recurrent urinary tract infections. Additionally, because estrogen restores suppleness to the vaginal tissues, it can be very useful both before and after vaginal surgical procedures (most commonly for stress urinary incontinence and pelvic organ prolapse).

Note: I commonly prescribe topical estrogen therapy, typically a small dab applied vaginally prior to sleep three times weekly.  It has proven helpful and effective in a variety of circumstances.

Kegel Exercises

Clinical studies have demonstrated that Kegel exercises can effectively improve certain domains of sexual function, particularly arousal, orgasm and satisfaction. This is not surprising given that the pelvic floor muscles are essential to arousal and orgasm, with weakness in these muscles resulting in reduced pelvic and vaginal blood flow and lack of adequate lubrication, painful intercourse and difficulty achieving climax.  Furthermore, Kegel exercises can be effective in the management of overactive bladder, stress urinary incontinence, and pelvic organ prolapse.

Stay Sexually Active: Use it or Lose it

Sexual intercourse can be painful after menopause because of anatomical and functional changes that result in difficulty in accommodating a penis.  This is particularly the case if one has not been sexually active on a regular basis.  Sexual activity is vital for maintaining the ability to have ongoing satisfactory sexual intercourse. Vaginal penetration increases pelvic and vaginal blood flow, optimizing lubrication and elasticity, while orgasms tone and strengthen the pelvic floor muscles that support vaginal functionLubricants can be used for women experiencing vaginal dryness and painful intercourse.

Lifestyle Modification

Pursuing a healthy lifestyle can provide some degree of relief from menopausal symptoms. These measures include a maintaining a healthy weight, a diet emphasizing plant-based proteins, fruits and vegetables, moderate exercise, sufficient quantity and quality of sleep, caffeine reduction, tobacco cessation and alcohol in moderation.

Bottom Line: Menopause is an inevitable part of the aging process with the absence of menstrual periods a welcome change for many women.  However, the cessation of estrogen production can cause a host of symptoms and consequences, particularly affecting the urinary and genital organs.  If symptoms are bothersome, there are numerous means by which to improve them. 

Wishing you the best of health,

2014-04-23 20:16:29

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

 

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Urinary Infections In Women

September 12, 2015

Andrew Siegel, MD    9/12/2015

shutterstock_femalebluepelvic

Bladder infections (a.k.a., cystitis) are common among women. Acute cystitis is a bladder infection that typically causes the following symptoms: pain/burning, frequent urination, and urinary urgency (“gotta go”). Additional symptoms that may occur are the following: urinating small volumes, bleeding and urinary incontinence (leakage). Microscopic inspection of urine usually shows bacteria, white blood cells and red blood cells.  80-90% of cystitis is caused by Escherichia coli, 5-15% by Staphylococcus and the remainder by less common bacteria including Klebsiella, Proteus, and Enterococcus.

The occasional occurrence of cystitis is a nuisance and oftentimes uncomfortable, but is usually easily treated with a short course of oral antibiotics. When bladder infections recur time and again, it becomes a major source of inconvenience and suffering for the patient and it becomes important to fully investigate the source of the recurrence.

Bladder infections occur when bacteria gain access to the urinary bladder, which normally does not have bacteria present. The short female urethra and the proximity of the urethra to the vagina and anus are factors that predispose to cystitis.

For an infection to develop, the vagina and urethra usually have to be colonized with the type of bacteria that can cause an infection (not the normal healthy bacteria that reside in the vagina), these bacteria must ascend into the bladder, and these bacterial must latch onto bladder cells.

Offense and Defense

Whether or not an infection develops is based upon the interaction of protective mechanisms (“defense”) and bacterial factors (“offense”). “Defense” factors include the following:

  • An acidic vagina, which inhibits the growth of infection-causing bacteria while promoting the growth of “good” bacteria such as lactobacilli
  • The unique layer that protects the bladder lining
  • Immune cells in the urine that prevent bacteria from sticking to the bladder cells
  • The dilution action of urine production and the flushing effect of urinating

Bacterial “offense” factors include in following:

  •  Tentacle-like structures that promote the attachment of bacteria to bladder cells
  • The capability of bacteria to evolve and develop resistance to antibiotics

Bladder Infections in Young Women

Women aged 18-24 years old have the greatest prevalence of bladder infections and sex is usually a key factor, hence the term “honeymoon cystitis.”

The following are risk factors for bladder infections:

  • A new sexual partner
  • Recent sexual intercourse
  • Frequent sexual intercourse
  • Spermicides, diaphragms and spermicide-coated condoms (which can increase vaginal and urethral colonization with E. Coli)

Bladder Infections in Older Women

Cystitis is common after menopause, based upon the following factors:

  • Female hormone (estrogen) deficiency, which causes a change in the bacterial flora of the vagina such that EColi replaces Lactobacilli
  • Age-related decline in immunity
  • Incomplete bladder emptying
  • Urinary and fecal leakage (incontinence), often managed with pads, which remain moist and contaminated and can promote movement of bacteria from the anal area towards the urethra
  • Diabetes (particularly when poorly controlled, with high levels of glucose in the urine that can be thought of as “fertilizer” for bacteria)
  • Neurological diseases that impair emptying or cause incontinence
  • Pelvic organ prolapse
  • Obesity
  • Poor hygiene

Complicated Infections

A urinary infection is considered complicated if:

  • It involves the upper urinary tracts (kidneys)
  • You are pregnant
  • Bacteria are resistant to antibiotics
  • There is a structural abnormality of the urinary tract
  • It occurs in immune-compromised patients including diabetics
  • It occurs in the presence of a foreign body such as a urinary catheter or stone

If It’s Not an Infection, What Is It?

It is important to distinguish a symptomatic urinary infection from asymptomatic bacteriuria, urethritis, vaginitis, and Painful Bladder Syndrome (PBS)/Interstitial Cystitis (IC).

  • Asymptomatic bacteriuria, common in elderly and diabetics, is the presence of bacteria within the bladder without causing an infection. This does not require treatment, which is futile and promotes selection of resistant bacteria. It should be treated only in pregnant women, in patients undergoing urological-gynecological surgical procedures, and in those undergoing prosthetic surgery (total knee replacement, etc.).
  • Urethritis is an infection in the urethra
  • Vaginitis is a vaginal infection
  • PBS/IC is a chronic inflammatory condition of the bladder that can mimic the symptoms of cystitis.

Diagnosis and Treatment

The diagnosis of cystitis is by urinalysis and culture. A urine specimen is obtained after cleansing the vaginal area and collection of a mid-stream specimen. At times, catheterization is necessary to obtain a specimen. Dipstick is the fastest and least expensive means of screening for an infection, but it is not very accurate, whereas microscope exam is much more accurate. The definitive test is urine culture and sensitivity, which will demonstrate the type of bacteria, the quantitative count, and those antibiotics that are most likely to be effective.

Treatment is antibiotics to eradicate the bacteria. In the case of recurrent cystitis, it is important to do an evaluation to rule out a structural cause. This generally involves imaging, often an ultrasound (using sound waves to obtain an image of the urinary tract), and a cystoscopy (a visual inspection of the urethra and bladder with a flexible scope). This will check the entire urinary tract, including the kidneys and bladder. Findings may be a dropped bladder, a stone within the urinary tract, a urethral stricture (a narrowing in the channel leading out of the bladder that causes an obstruction), a urethral diverticulum (a pocket connected to the urethra), or a fistula (abnormal connection between the colon and bladder), etc.

 Antibiotic Options For Those With Recurrent Urinary Infections

  • Patient-initiated treatment: a short course of antibiotics when the symptoms first occur. It is useful to first test your urine using a dipstick (although not perfect, it is great for home screening) when the symptoms of cystitis arise. This has proven to be safe, economical and effective.
  • Sexual prophylaxis: A single dose of antibiotic just before or after sexual activity if the infections are clearly sexually related
  • Daily antibiotic prophylaxis: A single dose of antibiotic is taken on a prophylactic basis every evening or every other evening to prevent recurrent cystitis.

Pearls To Help Keep Cystitis At Bay

  • Stay well hydrated to keep the urine dilute: “The solution to pollution is dilution.”
  • Wipe in a top-to-bottom motion after urination or bowel movementsAt minimum, urinate every four hours while awake to avoid an over-distended bladder.
  • Maintain a healthy weight.
  • Urinate after sex.
  • If infections are clearly sexual related, an antibiotic taken before or right after sex can usually preempt the cystitis.
  • If you are diabetic, maintain the best glucose control possible.
  • Seek urological consultation for recurrent infections to check for an underlying and correctable structural cause.
  • Methenamine: This chemical is broken down into formaldehyde, which can kill bacteria.
  • Cranberry extract: Cranberries contain proanthocyanidins that inhibit bacteria from adhering to the bladder cells. There are formulations of cranberry extract available to avoid the high carbohydrate load of cranberry juice.
  • Probiotics such as Lactobacillus: These bacteria promote healthy colonization of the vagina, production of hydrogen peroxide that is toxic to bacteria, maintenance of acidic urine, induction of an anti-inflammatory response in bladder cells, and inhibition of attachment between bacteria and the bladder cells.
  • D-Mannose: This sugar can inhibit bacteria from adhering to the bladder cells.
  • Estrogen cream: Applied vaginally, this can help restore the normal vaginal flora as well as uro-genital tissue integrity and suppleness.
  • Vaccination: Currently in research phases, the concept is an oral vaccine or vaginal suppository capable of providing immunity against the typical strains of bacteria that cause infections.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.