Perimenopause and urinary incontinence: Everything you need to know

Does a little bit of pee come out when you laugh, cough, or run for the bathroom? We all experience the occasional urine leak every now and then. But if it happens regularly, you may find it embarrassing or feel like it’s interfering with work, your self-esteem, or your relationships. If you can’t get to the toilet in time and it’s starting to impact your life, you might have a bladder control problem — aka urinary incontinence (UI).

Incontinence can happen at any time, and it gets more common as we age. So try not to feel any shame. A number of factors could be the cause of your leakage, including taking certain medicines, drinking alcohol or caffeine, or having a urinary tract infection (UTI). We also know pregnancy and childbirth can have a huge impact on bladder control.

However, if you’re somewhere between your late 30s and your 50s, your periods have started to become inconsistent, and you struggle to hold in your pee for any length of time, bladder weakness could be because of perimenopause — a sign that menopause is on the way.

Menopause is a normal life transition that most women go through, but everyone experiences it differently. For some, symptoms such as hot flashes, brain fog, and incontinence can feel difficult to live with, while others may not spot any signs at all. The good news is that if you’re finding things tricky, with the right treatment, urinary incontinence is manageable, and you don’t have to continue living with it. 

Here, Dr. Sameena Rahman, clinical assistant professor of obstetrics and gynecology, Northwestern Feinberg School of Medicine, Illinois, US, shares everything you need to know about urinary incontinence in perimenopause, including symptoms, causes, and best treatment options.

Key takeaways

• Up to 40% of middle-aged women (which is around the time perimenopause happens) experience loss of bladder control, and over 50% report incontinence problems postmenopause.
• Dropping estrogen levels combined with weakened pelvic floor muscles contribute to incontinence during perimenopause. 
• Treatment options are available to help with bladder leakage, including lifestyle tweaks, procedures, and medications. Your doctor will be able to help you come up with a plan to tackle it.  
• Kegel exercises can also do a lot to help strengthen your pelvic floor muscles and improve bladder control. Chat with your doctor so they can share everything you need to know before you get started.

Why can’t I hold my pee all of a sudden?

If you’ve been struggling to hold in your pee, as well as noticing other telltale signs of perimenopause, such as hot flashes, night sweats, and mood swings, your loss of bladder control could be menopause related. Urinary incontinence is “the involuntary loss or leakage of urine or loss of control of your bladder,” says Dr. Rahman. It can also make you need to pee more often than normal. It can affect anyone, but — thanks to falling hormone levels — it’s a common symptom during perimenopause and even more common after menopause.

Before we get started, it’s worth explaining that perimenopause and menopause often get mixed up, but they’re actually two separate things. Perimenopause describes the years leading up to menopause (which is the name given to your final period) being confirmed. This stage usually begins somewhere between your late 30s and 50s but most often in your 40s. You’re then diagnosed as having gone through menopause when you haven’t had a period for 12 months (this usually happens between the ages of 45 and 55). From then on, you are postmenopausal.

During perimenopause, your hormone levels go up and down before eventually dropping off. As well as regulating your menstrual cycle, estrogen plays an important role in keeping your bladder and urinary tract in check. “The muscles, ligaments, urethra, and vagina have receptors for [estrogen],” explains Dr. Rahman. 

When estrogen levels drop, this can cause the lining of your urethra (the tube where your pee comes out) to thin. Around the same time, your pelvic floor muscles — which support many of your lower organs, including your bladder and vagina — often start to relax with age, making you more prone to incontinence. 

Many women also experience a dip in collagen and elastin production at this stage of life, which are both important for strength and structure inside your vagina. This can make your vagina less elastic, which leaves your urethra weaker and means you may be more likely to leak urine.

The two most common types of urinary incontinence that affect women during perimenopause include:

1. Stress urinary incontinence: This involves leaking urine “with physical exertion such as jumping, running, or sports activities, or when sneezing, laughing or coughing,” says Dr. Rahman. If you’ve ever leaked a little pee while bouncing on a trampoline, this is what you’re experiencing.
2. Urge urinary incontinence: If you notice an “urgency or sudden desire to urinate that you cannot overcome,” this is urge incontinence, adds Dr. Rahman. It's one of the symptoms of an overactive bladder.

Some people can also experience mixed urinary incontinence, which is both stress and urge incontinence at the same time.

Urinary incontinence affects 30% to 40% of middle-aged women and over 50% postmenopause. If you frequently leak urine or struggle to get to the bathroom in time, a shift in your hormones might be to blame. Speak to your doctor for advice. Treatment options are available, and you don’t have to continue living with it.

How to spot the signs of urinary incontinence 

Are you often desperate to pee or struggling with accidental leaks? It’s a good idea to get checked out by your doctor if you notice any of the following:

• You leak urine during everyday activities, such as lifting, coughing, or exercising
• You feel unable to hold in your pee after a sudden, strong urge to urinate
• You suddenly pee without any warning or urge
• You are regularly unable to reach the toilet in time
• You wet the bed during sleep
• You leak during sexual activity

It’s even more important to speak to your health care provider if you experience any of the following:

• You can’t pass urine or empty your bladder, which can be a sign of urinary retention
• You start peeing eight or more times a day 
• You spot blood in your urine — known as hematuria
• You have bladder infection symptoms, including pain when you pee

They’ll be able to help you figure out what’s going on and direct you to a specialist if necessary.

How to manage perimenopause and menopause incontinence

If you’re struggling with leakage — and you suspect perimenopause might be to blame — know that there are a number of treatment options available to help you feel like yourself again. 

Remember, too, that you’re not alone in perimenopause. Flo’s safe community space, Secret Chats, allows you to anonymously share how you’re feeling and read through other people’s experiences of perimenopause symptoms. Download the app now to get involved in conversations like these, as well as keep track of your cycles and symptoms.

In some cases, a few simple lifestyle changes can make a big difference to incontinence. Chat with your doctor about the following treatment options:

Strengthening your pelvic floor

Taking care of your pelvic floor should be a priority at any age. This important group of muscles and ligaments that stretch from your pubic bone to your tailbone plays a crucial role in supporting your bladder, vagina, uterus, and bowel. Aside from controlling when you poop, pee, or pass gas, maintaining pelvic floor strength can support vaginal delivery during childbirth, and it plays a crucial role in sex, too. 

The truth is that your entire pelvic floor can weaken with age, which, in turn, can make you less able to control your bladder. That’s why doctors often recommend doing pelvic floor exercises, like Kegels, to strengthen the area. Regular little squeezes, as if you were trying to hold your pee midflow, is all it takes — and you can do them just about anywhere. 

To do your Kegel exercises, try the following:

• Find the right muscles: Your pelvic floor muscles are activated when you try to stop your flow of pee midstream, explains Dr. Rahman. Once you’ve figured out which muscles to contract, you can do Kegels anywhere at any time.
• Perfect your technique: The best way to do Kegels is to imagine you’re sitting on a marble. Tighten your pelvic muscles as if you’re lifting the marble. Try it for three seconds at a time, then relax for a count of three. Aim for three sets of 10 to 15 repetitions a day.
• If you need help: For extra guidance, seek out a pelvic floor physical therapist — like a personal trainer for your pelvic floor.

Cutting down on alcohol and caffeine 

There’s nothing wrong with enjoying a glass of wine every now and then or having a morning coffee to get the day started. But if you sometimes take your alcohol or caffeine (or both!) indulgence to excess, and you’re struggling with having less bladder control — now might be a good time to rethink this aspect of your lifestyle. “Limit consumption of alcohol, caffeine, and [fizzy] drinks,” advises Dr. Rahman, adding that these “can contribute to increased pressure on your bladder and irritate the lining.” In turn, this can make you need to go to the bathroom more often.

Maintaining a healthy weight 

Maintaining a healthy weight is a good idea for lots of reasons, and it can have its benefits for bladder issues, too. While weight gain due to menopause is common, if it gets into excessive weight gain, over time, this may strain and weaken your pelvic floor muscles, which can lead to less control for your bladder.

Try to aim for a healthy weight for you and your body type. A balanced diet that’s rich in whole grains, fruits, seeds, nuts, eggs, leafy green vegetables, legumes, lean proteins, and sources of healthy fat, like olive oil and avocados, is a good place to start. Reach out to your doctor for help if you feel like you could use some specific advice.

Giving bladder training a go

You might not have heard of bladder training techniques, but Dr. Rahman says they can really help with urinary incontinence. And there’s no class to attend because you can teach yourself. 

Bladder training is a type of behavioral treatment. The idea is that you retrain your brain and bladder by following a fixed schedule that includes “learning to control your stream and reducing the frequency of bathroom visits.” Using what doctors call “urge suppression techniques” to control your bladder can help if you feel an urge to pee before it’s time to go to the bathroom. This kind of self-training can take time and practice, so ask your doctor for advice if you’re thinking of trying it.

Switching up your workouts

If stress incontinence is the culprit for you, then low-impact exercise might be the way to go. Dr. Rahman says moves like jumping “may damage [your] pelvic floor more.” So you could try swimming, cycling, or yoga instead. But there are workarounds if you don’t want to forgo that high-intensity interval training class. “Sometimes, something simple like using incontinence underwear can safely get you through a workout or a run,” she adds.

Chatting with your doctor about treatment options

If your reduced bladder control is impacting your daily routine or quality of life, then it’s time to get help. Remember that your doctor is on hand to support and advise you during perimenopause, so don’t put off booking an appointment.

They might suggest a couple of different treatment options, depending on your symptoms, the type of incontinence you have, your medical history, and personal preference, such as:

• Medications (such as Mirabegron) that help to relax the muscle in the bladder by preventing it from contracting. It’s these contractions “that can lead to urgency, frequency, and loss of urine.” 
• Hormone therapy (previously known as hormone replacement therapy or HRT) isn’t generally given directly for incontinence in the same way it might be suggested for other perimenopause symptoms such as hot flashes and brain fog. However, vaginal estrogen therapy (which can come either as a cream, suppository that goes in your vagina, or a ring) can be very helpful if your urge incontinence is part of a wider condition called genitourinary syndrome of menopause or GSM. You may have GSM if you have:
  • Genital symptoms (dryness, irritation, and burning of the vagina and vulva)
  • Sexual symptoms (being less naturally lubricated and feeling pain during sex)
  • Urinary symptoms (being desperate to go to the bathroom all the time, getting UTIs, and experiencing bladder leakage)

If this sounds familiar, chat with your doctor, and they can help you decide whether it’s a good option for you.

• Medications that contain vaginal estrogen or DHEA (dehydroepiandrosterone, a hormone that helps trigger estrogen production). According to Dr. Rahman, these can “restore vaginal flora [healthy vaginal bacteria] and improve blood flow and the production of collagen to enhance the normal function of muscles, [the] urethra, and [the] vagina.”
• Procedures, such as Botox in the bladder for urge incontinence or urethral bulking injections (which is like a filler for the urethra) for stress incontinence. In more advanced cases, surgery may be considered. This may sound daunting, but if your doctor thinks this option could benefit you, they will clearly explain what it involves, and you can decide if it’s the right path to take. 
• Other treatment options, including “pessaries [devices inserted into your vagina] placed to help with the pelvic floor,” have been found to help with stress urinary incontinence. 

Reading up on biofeedback therapy

Biofeedback therapy is a type of mind–body technique. It teaches you to take control of certain involuntary bodily functions, such as your heart rate, breathing, and — you guessed it — muscle movements that cause you to pee. The good news is it’s been found to improve pelvic floor strength and decrease urinary incontinence for some people. 

Dr. Rahman explains how it works: “A pelvic floor therapist [gives] you feedback on how you are contracting and relaxing your muscles and how the tone of your pelvic floor muscles is responding to your exercises.” 

You can also buy a pelvic floor training device to use at home to help strengthen your pelvic floor. They’re usually made of silicone and slip inside like a tampon, and some models provide biofeedback advice via an app. Ask your doctor for more information if you think this could be an option to explore for you.

Caring for your well-being during perimenopause and after menopause

Everybody experiences perimenopause differently. As we’ve seen, certain lifestyle changes may be worth a try to ease certain troubling symptoms caused by perimenopause or menopause. For some people, such symptoms can be difficult to live with and may affect mental well-being, especially when combined with other factors like a high-pressure job, parenting, or caring for aging relatives. 

If you’re finding this to be a difficult time, support from like-minded people can really help. Open up to a doctor, family, and friends, or even the community on Flo’s anonymous Secret Chats space for support.