Can Perimenopause Affect Urinary Frequency and Urgency?
Yes, perimenopause directly causes urinary frequency and urgency through estrogen deficiency-related changes in the lower urinary tract, with these symptoms being particularly prominent during the perimenopausal transition and worsening postmenopausally.
Mechanism and Prevalence
The loss of estrogen during perimenopause causes significant physiological changes in the bladder and urethra that directly lead to urinary symptoms 1. Around 50% of postmenopausal women experience urinary urgency attributable to estrogen deficiency 2. The prevalence increases dramatically across menopausal stages: 13% in young women, 47% in middle-aged women, and 75% in older women 1.
Estrogen receptors are present throughout the lower urinary tract including the bladder, trigone, urethra, and pelvic floor musculature 3, 4. When estrogen levels decline, these tissues undergo atrophic changes that manifest as:
- Urinary urgency (sudden compelling desire to void) 2, 1
- Urinary frequency (increased voiding episodes) 5, 4
- Nocturia (nighttime voiding) 4
- Recurrent urinary tract infections 2
Clinical Evidence Across Menopausal Stages
Perimenopause represents the stage with the most pronounced impact on urinary symptoms 6. Research demonstrates that urinary urgency and stress incontinence are most frequent during the perimenopausal and postmenopausal stages, while premenopausal women exhibit significantly fewer symptoms 6. Notably, 70% of women relate the onset of urinary incontinence to their final menstrual period 4.
The perimenopausal stage shows greater impact on quality of life related to urinary symptoms compared to pre- or postmenopausal stages 6.
Pathophysiology
Estrogen deficiency causes multiple changes that contribute to urgency and frequency 4:
- Vaginal atrophy and pH changes that alter the microbiome 2, 1
- Loss of Lactobacillus species with increased colonization by uropathogens 2
- Decreased urethral pressure and mucosal integrity 3
- Altered detrusor muscle contractility 3
These changes can lead to detrusor overactivity, the most common cause of urinary urgency in women 1.
Treatment Implications
Vaginal estrogen is the recommended treatment for urinary urgency and frequency in perimenopausal and postmenopausal women 2, 7. Topical vaginal estrogen (intravaginal tablets, creams, or rings) reduces urinary frequency and urgency by approximately 1-2 fewer voids per 24 hours 7. It works by restoring vaginal pH, promoting lactobacillus-dominant flora, and reversing urogenital atrophy 2, 7.
Critical caveat: Systemic oral estrogen therapy should NOT be used for urinary symptoms, as it worsens incontinence rather than improving it (HR 1.53,95% CI 1.37-1.71 for new-onset incontinence) 7, 8. This represents a common pitfall—only vaginal estrogen provides benefit 8, 5.
First-line management should include behavioral therapies (fluid management, caffeine reduction, pelvic floor exercises) before or alongside vaginal estrogen 9. For persistent symptoms, antimuscarinic agents or β3-agonists can be added 9.
Special Considerations
Women undergoing bilateral oophorectomy as part of breast cancer treatment experience particularly severe and long-lasting urinary symptoms, with >90% experiencing urgency and frequency 2. Even in breast cancer patients, recent evidence supports vaginal estrogen when nonhormonal treatments fail, as topical estrogen has minimal systemic absorption and no concerning safety signals regarding cancer recurrence 2, 7.