Summary. The vulva, vagina, urethra, and bladder all have estrogen and androgen receptors. As these hormone levels fluctuate in perimenopause, the tissues that depend on these hormones undergo a structural change. Symptoms associated with these changes include vaginal dryness, itching, pain during intercourse, and urinary issues. Urinary issues may include urgency, increased frequency, painful urination, and recurrent UTIs (American Urological Association). 

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As estrogen levels decline, the vaginal walls often thin and lubrication often declines which can both lead to an increased likelihood of painful sex (Gandhi et al., 2016). Lactobacillus are the predominant microbiota in the biome of the vagina before the overall decline in estrogen which begins in perimenopause. Once estrogen declines the pH increases (shifts from acidic to alkaline) and the number of lactobacillus decreases, disrupting the bacterial population balance . When the balance of the microbiome is out of balance, there is an increased opportunity for pathogenic organisms to take over potentially leading to an increased susceptibility to infections. (Laniewksi & Herbst-Kralovetz, 2022)

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Not all incontinence is the same, and understanding the distinction between the two most common types — stress incontinence and urge incontinence — can help you have a more productive conversation with your care team. Stress incontinence occurs when physical pressure on the bladder — from coughing, sneezing, laughing, or exercise — overwhelms the urethral sphincter's ability to stay closed. It is primarily a structural issue, rooted in weakened pelvic floor muscles or urethral support, and is strongly associated with pregnancy, childbirth, and the connective tissue changes that accompany declining estrogen during perimenopause. Urge incontinence, by contrast, is driven by an overactive or unstable detrusor muscle — the bladder wall itself — which contracts involuntarily and sends a sudden, intense urge to urinate that can be difficult to defer. Leakage with urge incontinence tends to occur on the way to the bathroom rather than during physical exertion. Many people in the perimenopause transition experience mixed incontinence, a combination of both types, which underscores why a personalized evaluation matters: the underlying mechanisms — and therefore the most effective interventions — differ between them (Wasserman & Rubin, 2023).

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Women who suffer from urinary changes including symptoms in their urinary tract are 7x more likely to experience painful intercourse and are 4x more likely to have issues becoming sexually aroused. The two systems are linked, and treating urinary issues can have significant impacts on sexual health and quality of life. (Wasserman & Rubin, 2023)

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These physical symptoms and a woman's psychological well-being are closely linked. In the SWAN cohort, vaginal dryness, depressive symptoms, and anxiety each independently lowered sexual function scores across perimenopause, with effects beginning roughly 20 months before menopause (Avis et al., 2017) Treatment plans that address both the physical and psychological side of these changes are likely to be more effective than addressing either alone. 

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Naming. All of the changes related to these systems (Reproductive & Urinary) were grouped together in 2014, to be called Genitourinary Syndrome of Menopause (GSM); Genitourinary refers to both the reproductive & urinary systems. This replaces prior terminology of atrophic vaginitis or vulvovaginal atrophy, which did not fully represent the scope of symptoms or organs affected, and indicated the conditions as a disease state, rather than a spectrum of symptoms related to normal hormone changes through the life cycle. 

 

 

What next? Because the symptoms are linked to consistently lower levels of estradiol, this is a set of symptoms that can worsen as women move into later postmenopausal years. Unlike many symptoms of the perimenopause transition, they are unlikely to get better with time. Changes to these systems can also feel particularly uncomfortable given how closely they're tied not just to physical comfort but also to your sexual health and sense of wellbeing. 

 

There are actions which can be taken to alleviate symptoms and Flourish Through this phase of life.