Abstract
Objectives:
Most previous studies of genitourinary symptoms associated with menopause focus on comparisons of post-menopausal to pre-menopausal women and less is known about bladder health during menopause. We evaluated associations of menopause status and hormone use with bladder health and lower urinary tract symptoms (LUTS).
Methods:
Data were collected May 2022-December 2023 from a regionally representative cohort of community-dwelling adult women in the United States. Bladder health and LUTS were measured using validated questionnaires. Analyses included multivariable linear and logistic regression models.
Results:
Of 3,423 eligible participants, 3,126 responded to menopause and hormone use questions. Of these, 1,226 were pre-menopausal, 260 peri-menopausal, and 1,640 post-menopausal. Pre-menopausal women reported hormone use more often than peri-menopausal or post-menopausal women (38.3% vs 21.5% and 13.2%). Across multiple bladder health scales (BHS, range 0–100) and bladder function indices (BFI, range 0–100), peri-and post-menopause status were associated with worse scores compared to pre-menopause status. Peri-menopausal women were more likely to report urgency UI (OR 2.27, (95% CI, 1.49–3.46)) and other LUTS compared to pre-menopausal women. Hormone use was associated with worse bladder health in post-menopausal women (post-menopause/hormone −6.0 Overall BHS, (95% CI, −9.8 to −2.2) and BFI (post-menopause/hormone BFI −4.8, (95% CI, −7.4 to −2.2)).
Conclusions:
Promotion of bladder health and LUTS prevention are important as women approach the menopause transition. Hormone use was infrequently reported in peri- and post-menopausal women and associated with worse bladder health post-menopause.
Keywords: Menopause, Bladder Health, Urinary Symptoms, Women, Aging
Summary Sentences:
Promotion of bladder health and LUTS prevention are important as women approach the menopause transition. Hormone use was infrequently reported in peri- and post-menopausal women and was associated with worse bladder health post-menopause.
Introduction
The menopause transition is associated with systemic symptoms of hot flashes and night sweats. Additionally, local genitourinary symptoms (GUS) of urinary urgency, frequency and dysuria are common. However, most studies focus on comparisons of post-menopausal women to pre-menopausal women and less is known about bladder health during the menopause transition, often referred to as perimenopause. Lower urinary tract symptoms (LUTS) of incontinence and urinary tract infections increase with age, affecting approximately 60% of US women.1,2 While the menopause transition is a normal part of aging, world-wide estimates of moderate to severe vasomotor symptoms range from 12%–40% and for GUS from 13%–87%.3–5 Hormone therapy is commonly prescribed, either systemically or locally, as treatment or prevention of these symptoms. However, evidence suggests that systemic hormones may be associated with higher rates of incontinence than placebo while local low dose therapy is associated with improvement in GUS and urinary tract infections.1 Because associations of menopausal status and hormone use with bladder health or disease are not well established, we sought to examine the relationships between menopausal status with and without hormone use on overall bladder health, and prevalence of LUTS among women enrolled in a US population-based study. We expected worse bladder health and more urinary symptoms among peri-menopausal and post-menopausal women compared to pre-menopausal women. Based on prior studies suggesting hormone use is associated with increased prevalence of urinary incontinence, we hypothesized that hormone use would be associated with worse bladder health in peri-menopausal and post-menopausal women compared to premenopausal women with or without hormone use.
Methods
Study population and design
The RISE FOR HEALTH study, conducted by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium, is an ongoing regionally representative cohort study of US women to identify factors positively and negatively associated with bladder health and LUTS across the lifespan. Study design and procedures were published previously.6 Women residing in one of 50 counties surrounding nine university research centers were selected from a marketing database using simple and stratified probability sampling by age and race/ethnicity to achieve a regionally representative sample by these factors. Participants were invited to complete two 30-minute baseline surveys via a web portal; those who did not complete online surveys were mailed paper versions on two separate occasions. Eligibility included (1) birth as female or identification as cis-woman; (2) age ≥ 18 years; and (3) the ability to complete the surveys independently in English or Spanish. Individuals consented by completing the initial baseline survey from May 2022 through December 2023. The University of Minnesota Institutional Review Board (IRB) served as the single IRB of record.
The present analysis includes individuals who participated in the baseline survey and provided complete information on their age, self-reported menopausal status and hormone use.
Bladder health assessment
Bladder health was assessed using the validated PLUS Bladder Health Scales (BHS) and Bladder Function Indices (BFI).7 There are ten scales covering global bladder health, holding, urination, social-occupational, physical activity, intimacy, travel, emotion, perception and freedom. An adaptive behavior adjustment (ABA) is utilized to account for self-reported coping behaviors that affect individual variations between symptom severity and quality of life. The ABA includes use of absorbent products and toilet mapping.8 BFI consists of six items assessing dysbiosis (e.g., urinary tract infection), frequency, sensation, continence, comfort and emptying. These items were developed and evaluated as indices to assess periodicity, resilience, interference, and relative change in functions.
Scoring for the 10 BHS, 6 BFI, and ABA requires that more than 50% of the items within a scale be completed. The ABA value is the sum of behavior items and confidence indicators associated with each behavior. Adjusted BHS scores were used for analyses and range from 0 to 100, with zero representing the most unhealthy and 100 representing optimal health.7 The six individual BFIs were scored as the sum of index items within a domain, from 0 to 100, with higher values indicating better bladder function for that particular BFI domain. A total BFI score was created by taking the mean of the 6 individual BFI scores. The different domains of the BHS and BFI are reported as means ± standard deviations (possible range, 0–100).
LUTS assessment
LUTS were assessed using the 10-item Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index (LURN SI-10), which is a brief validated instrument that measures the frequency of 10 clinically significant LUTS including storage, voiding/emptying, and pain with bladder filling within the preceding 7 days.9 Most items are assessed on scales from 0 (“never”) to 4 (“every time”), except for daytime (≤3, 4–7, 8–10, ≥11 times/day) and nighttime (none, 1, 2–3, >3 times/night) urination frequency. For this analysis, we dichotomized symptoms based upon women reporting individual LUTS at least 50% or more of the time in the preceding 7 days, or daytime frequency ≥ 10 times/day, or nighttime frequency ≥ 3 times/night.
Menopause status
Menopause status was based on the question, Are you Pre-menopausal (have not gone through menopause/the change of life), Peri-menopausal (going through menopause), Post-menopausal (have gone through menopause [no period in 12 or more months] or had both of your ovaries removed).
Current Hormone Use
Hormone use was determined based on responses to questions assessing current vaginal estrogen and systemic menopausal hormone therapy. Among pre- and peri-menopausal participants, hormone use also included reporting current use of oral contraceptives, vaginal estrogen ring, hormonal intrauterine device, or hormone-containing patch. Women reporting use of a copper intrauterine device, diaphragm for contraception, or vaginal gel in addition to reporting none of the hormone products previously described were identified as non-hormone users.
Covariates
Covariates were selected based on their potential influence of the association between menopause and bladder function. Covariates included parity/delivery status, current pregnancy, body mass index, number of medical comorbidities, educational attainment, marital status, and income. Based upon clinical interest in whether hormone use might modify the association between menopause and bladder function, we also evaluated sociodemographic factors such as income and employment status that could affect access to hormone therapy options. Age is reported to describe the cohort; however, age was not included in multivariable models based on the significant correlation between age and menopausal status.10
Statistical Analysis
Descriptive statistics were used to compare sociodemographic and clinical characteristics across groups defined by self-reported menopausal status (i.e., pre-menopausal, peri-menopausal, post-menopausal).
Separate models regressed BHS and BFI scores on hormone use, stratified by menopausal status. Forest plots of BHS and BFI adjusted mean scores were generated to demonstrate the range of responses by hormone use within menopausal status categories. To describe the distribution of clinically significant LUTS, we reported the proportion of individuals reporting symptoms “about half the time or more”. Daytime and nighttime voiding frequencies were reported based on ordinal categories to differentiate normal frequencies from frequencies that are often associated with increased bother. Linear regression was used for the BHS and BFI and the total LURN SI-10 measures with adjustment for covariates and logistic regression was used for the individual symptoms. Multivariable models regressed individual LUTS and the global LURN SI-10 score on menopausal status groups among the total sample. For these analyses, pre-menopausal women served as the reference group.
Results
Within our analytic sample of 3,126 women, 1,226 identified as premenopausal, 260 as perimenopausal, and 1,640 were classified as postmenopausal (Table 1). Distributions by age appropriately reflected these menopausal status categories. As shown in Table 1, our sample comprised 361 (11.5%) Black women, 174 (5.6%) Asian women, 425 (13.6%) Hispanic women, 1,984 (63.5%) White women, and 182 (5.8%) women of mixed race, race not stated or responses in a combined category including n=9 women who reported American Indian or Alaska Native, n=12 who reported Middle Eastern or North African, n=4 women who reported Native Hawaiian or Other Pacific Islander, and three free text responses of Ashkenazic, Middle East, North African. Premenopausal women were more highly educated, less likely to be married, and more likely to be nulliparous. Postmenopausal women were less likely to be employed, more likely to be divorced, separated, or widowed, and reported greater history of hysterectomy and other co-morbidities. There were no meaningful differences in self-reported general health by menopausal status. In addition, no meaningful differences in household income, region of residence, or body mass index were seen by menopausal status. Any use of hormones was more prevalent among premenopausal women with 38.3% reporting use while 21.5% of peri-menopausal and 13.2% of post-menopausal women reported current hormone use.
Table 1.
Characteristics of RISE Survey Participants (N=3126a)
| Pre-Menopause N (%) N=1226 | Peri-Menopause N (%) N=260 | Post-Menopause N (%) N=1640 | |
|---|---|---|---|
| Age Group | |||
| 18–25 | 325 (26.5) | 1 (0.38) | 2 (0.12) |
| 26–44 | 732 (59.7) | 17 (6.5) | 14 (0.85) |
| 45–59 | 169 (13.8) | 203 (78.1) | 352 (21.5) |
| 60+ | 0 | 39 (15.0) | 1272 (77.6) |
| Race | |||
| Asian | 77 (6.3) | 15 (5.8) | 82 (5.0) |
| Black or African-American | 117 (9.5) | 50 (19.2) | 194 (11.8) |
| White | 693 (56.5) | 150 (57.7) | 1141 (69.6) |
| Hispanic | 247 (20.2) | 32 (12.3) | 146 (8.9) |
| Other raceb or multiple races | 67 (5.5) | 5 (1.9) | 32 (2.0) |
| Unknown | 25 (2.0) | 8 (3.1) | 45 (2.7) |
| Education | |||
| ≤High School Graduate | 94 (7.7) | 29 (11.2) | 265 (16.2) |
| Some College/Votech/Associate degree | 164 (13.4) | 43 (16.5) | 301 (18.4) |
| Bachelor’s degree | 513 (41.8) | 73 (28.1) | 423 (25.8) |
| Graduate Degree | 315 (25.7) | 72 (27.7) | 395 (24.1) |
| Missing | 6 (0.49) | 3 (1.2) | 24 (1.5) |
| Marital Status | |||
| Married | 463 (37.8) | 163 (62.7) | 927 (56.5) |
| Divorced/Separated/Widowed | 52 (4.2) | 52 (19.6) | 503 (30.7) |
| Unmarried w/partner | 119 (9.7) | 9 (3.5) | 47 (2.9) |
| Single | 556 (45.4) | 29 (11.2) | 116 (7.1) |
| Other | 4 (0.33) | 1 (0.38) | 23 (1.4) |
| Missing | 4 (0.33) | 1 (0.38) | 23 (1.4) |
| Employment | |||
| (1) Full time employed | 759 (61.9) | 160 (61.5) | 402 (24.5) |
| (2) Not 1 - Part time employed | 199 (16.2) | 36 (13.9) | 177 (10.8) |
| (3) Unemployed/retired/student/other or missing | 6 (0.49) | 28 (10.8) | 864 (52.7) |
| Household Income | |||
| <25,000 | 101 (8.2) | 19 (7.3) | 175 (10.7) |
| 25,000–49,999 | 181 (14.8) | 28 (10.8) | 250 (15.2) |
| 50–74,999 | 150 (12.2) | 32 (12.3) | 205 (12.5) |
| 75–99,999 | 153 (12.5) | 35 (13.5) | 182 (11.1) |
| 100–149,999 | 213 (17.4) | 37 (14.2) | 227 (13.8) |
| 150,000 or more | 221 (18.0) | 68 (26.2) | 225 (13.7) |
| DK/not reported | 207 (16.9) | 41 (15.8) | 376 (22.9) |
| Body Mass Index (BMI) | |||
| Underweight (<18.5 kg/m2) | 30 (2.5) | 4 (1.5) | 29 (1.8) |
| Healthy Weight (18.5 to <25 kg/m2) | 474 (38.7) | 82 (31.5) | 534 (32.6) |
| Overweight (25 to <30 kg/m2) | 289 (23.6) | 70 (26.9) | 439 (26.8) |
| Obese (30+ kg/m2) | 389 (31.7) | 86 (33.1) | 517 (31.5) |
| Unknown | 44 (3.6) | 18 (6.9) | 121 (7.4) |
| Parity/Delivery | |||
| Nulliparous | 771 (62.9) | 107 (41.2) | 535 (32.6) |
| 1 vaginal parity | 82 (6.7) | 22 (8.5) | 134 (8.2) |
| 2 vaginal parity (or 1 vaginal delivery /1 C-section delivery) | 149 (12.2) | 49 (18.9) | 389 (23.7) |
| 3 vaginal parity or more (at least 1 vaginal delivery) | 112 (9.1) | 41 (15.8) | 352 (21.5) |
| C-section only deliveries | 108 (8.8) | 39 (15.0) | 164 (10.0) |
| Any Hysterectomy | |||
| Yes | 31 (2.5) | 48 (18.5) | 445 (27.1) |
| General Health Status | |||
| Excellent/Very Good | 155 (12.6) | 30 (11.5) | 181 (11.0) |
| Good | 417 (34.0) | 98 (37.7) | 596 (36.3) |
| Fair | 111 (9.1) | 22 (8.5) | 185 (11.3) |
| Poor | 15 (1.2) | 2 (0.77) | 18 (1.1) |
| Comorbidities (%) c | |||
| 0 | 520 (42.4) | 87 (33.5) | 261 (15.9) |
| 1 | 265 (21.6) | 43 (16.5) | 320 (19.5) |
| 2 | 255 (20.8) | 55 (21.2) | 303 (18.5) |
| 3 | 99 (8.1) | 29 (11.2) | 246 (15.0) |
| 4+ | 86 (7.0) | 46 (17.7) | 509 (31.0) |
| Any current hormone use | 469 (38.3) | 56 (21.5) | 216 (13.2) |
| Any current/previous bladder specific treatmentd | 34 (2.8) | 19 (7.3) | 174 (10.6) |
Excludes 3 women missing age, 266 women missing menopausal status, and 28 women missing hormone use.
Other race category includes the following responses that were combined for this Table: American Indian or Alaska Native n=9; Middle Eastern or North African n=12, Native Hawaiian or Other Pacific Islander n=4; Free text responses of Ashkenazic, Middle East, North African
Comorbidities include: diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, osteoarthritis, inflammatory arthritis, sleep apnea, kidney failure, depression, anxiety, and neurologic disease. Neurologic disease was yes/no for any of the following: cerebral palsy, Parkinson’s disease, multiple sclerosis, spinal stenosis, spinal disc disease, spinal nerve damage, or sciatica, stroke, and spina bifida.
Includes self-reported operation for urine leakage, pessary, onobotulinumtoxin, bladder stimulator/pacemaker, pelvic muscle exercises, or medications for overactive bladder symptoms.
Examining Bladder Health Scales, we noted little difference in bladder health scores across all the scales by use of hormones in premenopausal women (Figure 1). However, in both perimenopausal and postmenopausal women, the use of hormones was associated with lower bladder health scores across virtually all scales. When we assessed associations between hormone use and BFI, we again saw no difference in scores by hormone use among premenopausal women (Figure 2). However, among postmenopausal women, hormone use was associated with lower scores across all BFI relative to non-users. Among perimenopausal women, hormone use was associated with lower scores in the domains of frequency, sensation, and emptying among hormone users relative to non-hormone users.
Figure 1 -.
Adjusteda mean scores among Global Bladder Health Scale and Bladder Health Subscales among users and non-users of hormones stratified by menopausal status
a Adjusted for parity/delivery status (reference is nulliparous), currently pregnant, body mass index, comorbidity count (0, 1, 2, 3, 4+), education (4 categories), marital status (5 categories), and income (7 categories)
Figure 2 -.
Adjusteda mean scores among Bladder Function Indices among users and non-users of hormones stratified by menopausal status.
a Adjusted for parity/delivery status (reference is nulliparous), currently pregnant, body mass index, comorbidity count (0, 1, 2, 3, 4+), education (4 categories), marital status (5 categories), and income (7 categories)
As shown in Table 2, BHS and BFI scores did not differ by hormone use among pre-menopausal women. The magnitude of the BHS mean score differences between hormone users and non-users in perimenopausal women ranged from 3 to 8 points on a 100-point bladder health scale but was statistically significant only for the urination scale. The overall difference was a 5.3-point lower score. Hormone use versus non-use in postmenopausal women was associated with mean BHS score differences ranging from 5 to 6 points lower and virtually all differences were statistically significant. Among perimenopausal women, hormone use versus non-use was associated with a trend toward lower mean BFI, including a 9-point lower functional index score for emptying, a 7-point lower score for frequency, and 5.5-point lower score for sensation (Table 2); however, only the frequency index reached statistical significance. Among post-menopausal women, hormone use versus non-use was associated with significantly lower scores across all BFI, except sensation, with a range from 5.1 to 6.2-point lower scores. Supplementary Tables 1 and 2 show the numerical data corresponding with Figures 1 and 2 related to bladder health and bladder function among hormone users and non-users stratified by menopausal status.
Table 2.
Adjusteda mean score differences for all Bladder Health Scales and Bladder Function Indices between users and non-users of hormones stratified by menopausal status.
| PRE-MENOPAUSAL (N=1226) | PERI-MENOPAUSAL (N=240) | POST-MENOPAUSAL (N=1640) | ||||
|---|---|---|---|---|---|---|
| Covariates | No Current hormonal use N=757 | Current hormonal use N=469 | No Current hormonal use N=204 | Current hormonal use N=56 | No Current hormonal use N=1424 | Current hormonal use N=216 |
| Least Square Mean Difference (95%CI) | Least Square Mean Difference (95%CI) | Least Square Mean Difference (95%CI) | ||||
| Bladder Health Scales | ||||||
| 1 Overall Bladder Health | 0.2 (−2.4, 2.9) | −5.3 (−13.4, 2.8) | −6.0 (−9.8, −2.2) | |||
| 2 Holding | 2.4 (−0.5, 5.3) | −4.2 (−13.1, 4.7) | −4.4 (−8.5, −0.3) | |||
| 3 Urination | 2.6 (−0.1, 5.2) | −8.1 (−16.0, −0.3) | −5.8 (−9.6, −2.1) | |||
| 4 Social/Occupational | 2.1 (−0.7, 4.7) | −5.9 (−14.9, 3.1) | −4.5 (−8.5, −0.4) | |||
| 5 Physical Activity | 1.5 (−1.5, 4.5) | −4.7 (−14.0, 4.6) | −4.4 (−8.8, 0.1) | |||
| 6 Intimacy | 1.7 (−1.1, 4.6) | −5.4 (−14.6, 3.9) | −5.9 (−10.1, −1.7) | |||
| 7 Travel | 0.7 (−2.2, 3.7) | −5.9 (−14.8, 3.0) | −4.6 (−8.8, −0.4) | |||
| 8 Emotion | 1.8 (−1.2, 4.7) | −4.3 (−13.8, 5.1) | −5.6 (−9.8, −1.4) | |||
| 9 Perception | 2.0 (−1.0, 5.1) | −7.5 (−16.7, 1.7) | −5.5 (−9.6, −1.3) | |||
| 10 Freedom | 1.8 (−1.0, 4.6) | −3.4 (−12.4, 5.6) | −5.0 (−9.1, −0.9) | |||
| Bladder Function Indices | ||||||
| Total Average Score | −0.1 (−2.1, 1.9) | −3.4 (−9.1, 2.4) | −4.8 (−7.4, −2.2) | |||
| Comfort | 0.4 (−2.5, 3.3) | 1.0 (−7.4, 9.4) | −5.1 (−8.7, −1.5) | |||
| Frequency | −1.3 (−4.3, 1.8) | −6.9 (−15.3, 1.4) | −5.4 (−9.2, −1.5) | |||
| Sensation | 0.5 (−2.4, 3.5) | −5.5 (−13.5, 2.5) | −3.3 (−7.0, 0.3) | |||
| Emptying | 0.3 (−2.8, 3.4) | −9.3 (−17.7, −1.0) | −5.7 (−9.8, −1.7) | |||
| Continence | −0.3 (−3.1, 2.5) | 0.3 (−7.4, 8.0) | −3.6 (−6.9, −0.3) | |||
| Bios/UTI History | −0.4 (−2.9, 2.1) | −2.0 (−9.3, 5.3) | −6.2 (−9.0, −3.4) | |||
Adjusted for parity/delivery status (reference is nulliparous), currently pregnant, body mass index, comorbidity count (0, 1, 2, 3, 4+), education (4 categories), marital status (5 categories), and income (7 categories)
Negative values indicate lower bladder health
Table 3 shows the association of menopausal status with LURN SI-10 symptoms. Perimenopausal women were 1.5 to 2.3 times more likely to experience urgency, urgency or stress urinary incontinence, or urological pain 50% or more of the time in the preceding 7 days compared to premenopausal women. The 95% confidence intervals across all risk estimates showed statistical significance. Furthermore, perimenopausal women were 2.3 times more likely to void 3 or more times per night (95%CI, 1.2–4.5) compared to premenopausal women. Among postmenopausal women, there was a trend toward increased prevalence of urgency urinary incontinence (OR=1.3, 95%CI, 0.9–1.8), and a significantly greater prevalence of voiding more than 3 times per night (OR=1.9, 95%CI, 1.2–3.2) compared to premenopausal women.
Table 3:
Association between Menopausal Status and LUTS
| PRE-MENOPAUSAL N = 1226 | PERI-MENOPAUSAL N = 260 | POST-MENOPAUSAL N = 1640 | ||||
|---|---|---|---|---|---|---|
| LURN Symptoms ≥50% of time | n (%) | Ref | n (%) | OR* (95%CI) | n (%) | OR* (95%CI) |
| Urgency | 181 (14.9) | 1.0 | 60 (23.3) | 1.50 (1.05– 2.14) | 346 (21.4) | 1.03 (0.80–1.34) |
| Urgency UI | 81 (6.7) | 1.0 | 46 (17.8) | 2.27 (1.49–3.46) | 239 (14.8) | 1.31 (0.95–1.81) |
| Stress UI | 69 (5.7) | 1.0 | 39 (15.1) | 2.00 (1.28–3.13) | 152 (9.4) | 0.88 (0.61–1.26) |
| Pain | 50 (4.1) | 1.0 | 21 (8.2) | 1.91 (1.06–3.45) | 37 (2.3) | 0.39 (0.22–0.67) |
| Daytime voiding - ≥10 times/day | 49 (4.1) | 1.0 | 19 (7.7) | 1.72 (0.96–3.11) | 72 (4.8) | 0.97 (0.60–1.55) |
| Nighttime voiding ≥3 times/night | 29 (2.4) | 1.0 | 16 (6.2) | 2.29 (1.16–4.51) | 106 (6.5) | 1.94 (1.15–3.26) |
Adjusted for parity/delivery status (reference is nulliparous), currently pregnant, body mass index, comorbidity count (0, 1,2, 3, 4+), education (4 categories), marital status (5 categories), and income (7 categories)
We assessed the distribution of the same LURN SI-10 symptoms among hormone users and non-users within menopausal status groups (Table 4). The prevalence of LURN symptoms in the preceding 7 days 50% or more of the time, or excessive daytime and nighttime voiding, did not vary by hormone use among premenopausal or postmenopausal women. However, among peri-menopausal and post-menopausal women, the prevalence of urgency, urgency UI and stress urinary incontinence symptoms occurring 50% or more of the time in the preceding 7 days was reported more often among hormone users; however, no within group comparisons reached statistical significance.
Table 4:
Distribution of LUTS among women who did and did not use hormones stratified by menopausal status.
| PRE-MENOPAUSAL N = 1226 | PERI-MENOPAUSAL N = 260 | POST-MENOPAUSAL N = 1640 | ||||
|---|---|---|---|---|---|---|
| No Hormone N = 757 | Any Hormone N = 469 | No Hormone N = 204 | Any Hormone N = 56 | No Hormone N = 1424 | Any Hormone N = 216 | |
| LURN Symptoms >=50% of time in last 7 days | n (%) | n (%) | n (%) | n (%) | n (%) | n (%) |
| Urgency | 111 14.8) | 70 (15.0) | 42 (19.6) | 18 (32.1) | 304 (21.7) | 42 (19.6) |
| Urgency UI | 52 (6.9) | 29 (6.2) | 33 (16.3) | 13 (23.2) | 214 (15.3) | 25 (11.6) |
| Stress UI | 47 (6.2) | 22 (4.7) | 28 (13.9) | 11 (19.6) | 130 (9.3) | 22 (10.3) |
| Pain | 35 (4.7) | 15 (3.2) | 16 (7.9) | 5 (9.1) | 31 (2.2) | 6 (2.8) |
| LURN VOIDING | ||||||
| Daytime voiding ≥10 times/day | 34 (4.6) | 15 (3.3) | 14 (7.3) | 5 (9.3) | 63 (4.8) | 9 (4.5) |
| Nighttime voiding ≥3 times/night | 17 (2.3) | 12 (2.6) | 11 (5.4) | 5 (8.9) | 87 (6.2) | 19 (8.8) |
LURN = Lower urinary tract research network
UI = Urinary incontinence
No comparisons are statistically significant within each hormone status group
Discussion
Among women in this cross-sectional analysis of the RISE FOR HEALTH study, we found associations between bladder health, bladder function, and LUTS according to menopausal status and hormone use. Our data show that peri-menopausal and post-menopausal women reported worse bladder health and bladder function scores compared to pre-menopausal women and peri-menopausal women were more likely to report multiple LUTS compared to pre-menopausal women. Additionally, among peri-menopausal and post-menopausal women, current use of hormones was associated with reporting worse bladder health and bladder function as well as more LUTS.
In the RISE FOR HEALTH cross-sectional analysis, peri-menopausal status was more consistently associated with LUTS relative to premenopausal women than was post-menopausal status relative to pre-menopausal women. At least two longitudinal cohort studies have reported similar findings. Compared to pre-menopausal women in the Study of Women Across the Nation (SWAN), early peri-menopausal women were 30% more likely and late peri-menopausal women were 50% more likely to develop monthly or more frequent incontinence.11 In contrast, post-menopausal women were approximately half as likely to develop this degree of incontinence.11 In the British National Survey of Health and Development (NSHD) cohort, women who became perimenopausal (‘pre-peri’) or those experiencing perimenopause for >1 year (‘peri-peri’) were more likely to have symptoms of stress urinary incontinence than were postmenopausal women.10 Menopause transition status was not associated with urgency urinary incontinence. Although this lends support to the idea that peri-menopausal status may pose a distinct period of risk for the experience of LUTS, at least two longitudinal cohort studies have found no association between menopausal status and development of urinary incontinence.12,13
Other cross-sectional studies have found urinary incontinence or LUTS to be more broadly prevalent among post-menopausal than peri-menopausal women, more prevalent among peri-menopausal than post-menopausal women, or not different between peri-menopausal and post-menopausal women.13–19 Additional research is needed to understand the differences in urinary incontinence and LUTS between peri- and post-menopausal women.
The role of hormone therapy in mitigating LUTS remains controversial. While studies have shown that systemic hormone therapy could exacerbate urinary symptoms, especially urinary incontinence, localized vaginal estrogen therapies have shown promise in alleviating overactive bladder symptoms and other genitourinary symptoms of menopause.1 Legendre et al. supported this view by suggesting that different administration routes of estrogen can have contrasting effects on urinary incontinence, emphasizing the necessity for personalized treatment strategies.20 Results from the RISE FOR HEALTH study are cross-sectional and thus causality cannot be determined. Women with greater burden of LUTS or worse bladder health may be more likely to use hormone therapy as a potential treatment; however, it is notable that less than a third of women in the RISE FOR HEALTH study reported current hormone use.
While the current literature provides valuable insights, several gaps remain. Notably, the impact of specific risk factors across the lifespan, such as obesity, smoking, and physical activity, on the development of LUTS and reduced bladder health during menopause requires further exploration. Moreover, longitudinal studies could enhance our understanding of how urinary symptoms evolve over the menopause transition, rather than relying solely on cross-sectional data. Only a small number of cohort studies have followed a cohort of women across the menopause transition and determined impact on LUTS, such as the Study of Women’s Health Across the Nation. Recruitment strategies focused on enrolling a cohort of women that is representative of the broader US population also facilitates evaluation of factors that may differentially affect women experiencing health disparities.11–13,21
Strengths of the current study include its sample of adult women representative of the regional demography that reflects much of the United States population. The cohort also includes many women in the peri-menopausal period, permitting robust estimates of bladder health and LUTS among women in different stages of the menopause transition. A validated questionnaire to assess urinary symptoms and use of a brief self-reported menopausal status question permit a novel assessment of how these conditions may relate to bladder health across the lifespan of adult women. A limitation of the current evaluation includes the cross-sectional design, which does not permit an assessment of causality. Data collection for a longitudinal phase of the RISE for Health study is in progress. It is possible that self-reported hormone use and menopausal status could lead to misclassification. The analysis of hormone data includes only current use, which does not provide an assessment of whether former use is associated with urinary symptoms or bladder health. The lack of statistical significance across the bladder health scales by hormone use in perimenopausal women is likely due to sample size issues related to the number of perimenopausal women in our sample. The minimum important difference for the BHS and BFI has not been established and so we are not able to determine whether statistically significant associations between hormone users and non-users are clinically meaningful.
Conclusions
The association between menopausal status and bladder health and function is complex and multifaceted. Based on our findings, efforts to promote bladder health and prevent LUTS should target women prior to the menopausal period. More focus on pre- and peri-menopausal women may be warranted for symptom assessment, screening in primary care, and prevention interventions. While it is not possible to determine the directionality of the association between hormone use and bladder health and LUTS, these results do not support routine recommendation of hormone use in the peri-menopausal and post-menopausal periods. Future research should continue to investigate the nuances of this relationship, enabling more effective prevention and management strategies for women with and without LUTS before and during menopause.
Supplementary Material
Supplementary Table 1. Adjusteda mean scores among Bladder Health Scales and Bladder Function Indices stratified by menopausal status.
Supplementary Table 2. Adjusteda mean scores among Bladder Health Scales and Bladder Function Indices among users and non-users of hormones stratified by menopausal status.
Financial Support:
Provided through the following NIH awards: This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) at the National Institutes of Health (NIH) by cooperative agreements [U24 DK106786, U01 DK106853, U01 DK126045, U01 DK106858, U01 DK106898, U01 DK106893, U01 DK106827, U01 DK106908, U01 DK106892]. Additional funding from: National Institute on Aging, NIH Office of Research on Women’s Health.
Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium
Research Centers and Investigators
Loyola University Chicago -Maywood, IL (U01DK106898)
Multi-Principal Investigators: Linda Brubaker, MD; Colleen Fitzgerald, MD, MS
Investigators: Marian Acevedo-Alvarez, MD; Cecilia T. Hardacker, MSN, RN, CNL; Jeni Hebert-Beirne, PhD, MPH
Northwestern University - Chicago IL (U01DK126045)
Multi-Principal Investigators: James W. Griffith, PhD; Kimberly Sue Kenton, MD; Melissa Simon, MD, MPH
Investigators: Oluwateniola Brown, MD; Julia Geynisman-Tan, MD; Margaret Mueller, MD
University of Alabama at Birmingham - Birmingham, AL (U01DK106858)
Multi-Principal Investigators: Alayne D. Markland, DO, MSc; Camille P. Vaughan, MD, MS;
Investigators: Tamera Coyne-Beasley, MD, MPH, FAAP, FSAHM; Kathryn L. Burgio, PhD; Cora E. Lewis, MD, MSPH; Gerald McGwin, Jr., MS, PhD; Beverly Rosa Williams, PhD.
University of California San Diego - La Jolla, CA (U01DK106827)
Principal Investigator: Emily S. Lukacz, MD; D. Yvette LaCoursiere, MD, MPH
Investigators: Sheila Gahagan, MD, MPH; Jesse Nodora, DrPH.
University of Michigan - Ann Arbor, MI (U01DK106893)
Principal Investigator: Lisa Kane Low, PhD, CNM, FACNM, FAAN
Investigators: Janis M. Miller, PhD, APRN, FAAN; Abby Smith, PhD
University of Minnesota (Scientific and Data Coordinating Center) - Minneapolis MN (U24DK106786)
Multi-Principal Investigators: Gerald McGwin, Jr., MS, PhD; Kyle D. Rudser, PhD
Investigators: Sonya S. Brady, PhD; Cynthia S. Fok, MD, MPH; Bernard L. Harlow, PhD; Peter Scal, PhD; Todd Rockwood, PhD.
University of Pennsylvania – Philadelphia, PA U01DK106892)
Multi-Principal Investigators: Diane K. Newman, DNP; Ariana L. Smith, MD;
Investigators: Amanda Berry, MSN, CRNP; Andrea Bilger, MPH; Terri H. Lipman, PhD; Heather Klusaritz, PhD, MSW; Ann E. Stapleton, MD; Jean F. Wyman, PhD
Washington University in St. Louis - Saint Louis, MO (U01DK106853)
Principal Investigator: Siobhan Sutcliffe, PhD, ScM, MHS
Investigators: Aimee S. James, PhD, MPH; Jerry L. Lowder, MD, MSc; Melanie R. Meister, MD, MSCI.
Yale University - New Haven, CT (U01DK106908)
Principal Investigator: Leslie M. Rickey, MD, MPH
Investigators: Deepa R. Camenga, MD, MHS; Shayna D. Cunningham, PhD.
Steering Committee Chair: Linda Brubaker, MD. UCSD, San Diego. (January 2021-)
NIH Program Office: National Institute of Diabetes and Digestive and Kidney Diseases, Division of Kidney, Urologic, and Hematologic Diseases, Bethesda, MD.
NIH Project Scientist: Jenna Norton, PhD, MPH
Footnotes
Conflict of Interest: ESL: Pathnostics – Consultant/Advisory Board; UpToDate – Royalties; Emmi Solutions – consultant; Stapleton: GSK: consultant; No other authors reported any COI
Disclaimers: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Contributor Information
Camille P. Vaughan, Division of Geriatrics & Gerontology, Department of Medicine, Emory University, Birmingham/Atlanta VA Geriatric Research Education and Clinical Center, Atlanta, GA.
Alayne D. Markland, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, and the Geriatric Research, Education, and Clinical Center at the Birmingham Veterans Affairs Health Care System; Birmingham, AL.
Gerald McGwin, Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.
Emily S. Lukacz, University of California San Diego, Department of Obstetrics, Gynecology & Reproductive Sciences, La Jolla, CA..
Sonya S. Brady, University of Minnesota Medical School, Department of Family Medicine and Community Health.
D Yvette Lacoursiere, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Diego, La Jolla, CA.
Jean F. Wyman, School of Nursing, University of Minnesota, Minneapolis, MN.
Siobhan Sutcliffe, Washington University School of Medicine, Department of Surgery, Division of Public Health Sciences, St. Louis, MO..
Ariana L. Smith, Perelman School of Medicine at the University of Pennsylvania, Division of Urology, Department of Surgery, Philadelphia, PA.
Kimberly Kenton, Section of Urogynecology & Reconstructive Pelvic Surgery, Department of Obstetrics & Gynecology, University of Chicago, Chicago, IL.
Ann Stapleton, Department of Medicine, Division of Allergy and Infectious Disease, University of Washington, Seattle, WA.
Linda Brubaker, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, San Diego, CA.
Bernard L Harlow, Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Table 1. Adjusteda mean scores among Bladder Health Scales and Bladder Function Indices stratified by menopausal status.
Supplementary Table 2. Adjusteda mean scores among Bladder Health Scales and Bladder Function Indices among users and non-users of hormones stratified by menopausal status.