Abstract
The menopause heralds a time of significant change in the hormonal milieu of a woman. This may present both physical and emotional challenges to the clinician, encompassing a wide time frame before and after the onset of menopause. While some symptoms are quite specific to menopause, some are not. The most commonly encountered problems in the early postmenopausal period in the urogynecological setting are: utero-vaginal/pelvic organ prolapse (POP), urinary incontinence (UI), recurrent urinary tract infections (RUTI) and uro-genital atrophy. This article reviews the presentation, assessment and initial management of these problems. A comprehensive review of the management of these conditions is beyond the scope of this article.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
Prolapse
• Prolapse is common in postmenopausal women but careful evaluation of its impact on quality of life should be undertaken before considering surgical correction.
• Upto 30% women who undergo prolapse surgery will require a second procedure, and lifetime risk of having prolapse surgery by the age of 80 years, in UK is 9.5%.
• Recurrent prolapse should only be managed by those with appropriate training and multi-disciplinary support teams.
• Vaginal use of mesh for prolapse repairs is not routinely recommended.
Overactive bladder
• Affects almost one out of eight women; incidence increases with age.
• Conservative management with modification of fluid intake and bladder training are the key steps.
• Anti-cholinergics are mainstay of drug treatment but side effects are common. Extended-release preparations have a better side-effect profile.
• Intravesical Botulinum A toxin injections are an effective alternative if anticholinergics are unsuccessful. The effects last from 3–12 months and the injections can be repeated. Upto 10% patients may experience voiding difficulties requiring intermittent self-catheterization.
Stress incontinence
• Prevalence peaks around peri-menopause. Pelvic floor muscle training is the first-line management.
• Midurethral slings are currently the most popular and cost-effective intervention. They are usually done as day cases and can be done under local anesthetic and sedation.
Recurrent UTI
• Age-related rise in incidence, predisposing factors include: lack of estrogen, urinary incontinence, presence of a cystocele, increased post-void residuals, diabetes and institutionalized elderly women.
• Persistent infection should raise suspicion of tumors/calculi or other pathology.
• Vaginal estrogens reverse underlying atrophy and can reduce recurrent urinary tract infections. Long-term antibiotic prophylaxis for 6–12 months may also be helpful.