It's impossible -- both anatomically and, most important, functionally -- to separate the reproductive and urinary tracts in women," says Scarborough, Ontario, urogynecologist Dr. William Easton. "They're glued together, and they function together. When one goes wrong, it invariably involves components of the whole system, because of the way the system is structured."
Easton looks after disorders of the lower urinary tract and its support structures, "the pelvic floor, the muscles that support the bladder, the uterus, the vagina, and so on." Recognizing the inseparable nature of the genitourinary system, he says, is crucial to understanding the problems that can beset women, especially postmenopausal women. Menopause is a watershed in a woman's health. As the ovaries stop producing estrogen, several changes take place.
One of the biggest is atrophic vaginitis, in which the normal mucous secretions of the vagina disappear, and the vaginal tissue becomes thin, fragile and dry. The most obvious effect is painful intercourse.
The loss of estrogen support, though, also affects the bladder, which is an estrogen-dependent organ as well, Easton observes. "The lower third of the bladder is formed from the same tissue that forms the upper third of the vagina, so an estrogen-deficient bladder is more likely to be affected by infections. These women develop urinary frequency and urgency, and in some cases, urgency incontinence."
Atrophic vaginitis and accompanying bladder problems are easily treated with estrogen vaginal cream, applied three times a week at bedtime. Within eight to 10 weeks, the thickness and moisture content of the vagina are renewed, and the natural defense mechanisms of the bladder and the tissue around the urethra (the urinary canal) are reactivated and continence restored. The therapy has to be continued indefinitely to maintain the condition of the tissue, though most women get down to once- or twice-a-week therapy.
The lower genital tract will atrophy and cause problems in all women to varying degrees. Overweight women may have less trouble, because fat converts a hormone produced by the adrenal gland into a form of estrogen, but they have an increased incidence of uterine (endometrial) cancer and are at greater risk of breast cancer, in addition to other problems linked to obesity, such as hypertension and diabetes.
The other major problem for postmenopausal women is vaginal or utero-vaginal prolapse, loss of support for the genital organs because of congenital connective-tissue weakness, obesity or childbirth, which undermine the muscles of the pelvic floor. (For treatment approaches, see the story on incontinence on page TK.) Because all the genitourinary organs are hung together, when the genital organs fall out of place, the bladder goes with them. If it falls too far, the mechanism that maintains continence goes awry, causing low backache and discomfort.
"When it descends further," Easton says, "the incontinence goes away because the bladder's so twisted, but they can't empty it and they start to get recurrent infections. The best defense against bladder infections is getting it all out every time you pee. It doesn't matter how often you go, so long as you empty your bladder. If you leave that little cesspool of urine behind, you get infected. So prolapse and atrophy I think are the two big categories with problems of the vagina."
Women over 50 -- particularly those who are monogamous -- aren't as likely to suffer vaginitis, or vaginal infections, as premenopausal women, but atrophic vaginal mucosal tissue is still susceptible to noxious agents, such as candidiasis, or yeast infection. Almost invariably it's caused by autoinnoculation: You give them to yourself, by contamination from the lower bowel or rectum. The resulting burning and itching are easily treated with antibacterial medication. Women using a long-term vaginal estrogen cream, unfortunately, may be more susceptible to yeast infections, because estrogen creates a lusher environment for bacteria.
ERT (estrogen replacement therapy) for post-menopausal women is still controversial, because of suggestions that long-term ERT increases the risk of breast and uterine cancer. With biannual mammograms and careful monitoring, though, says Easton, "the risks are minimal, and the benefits are huge."
To those who argue that natural is better -- that diet, exercise and herbal remedies are the way to deal with menopausal changes -- Easton is very clear: Diet is important, and exercise is of great benefit in preventing osteoporosis and maintaining the cardiovascular system -- there's even a herbal remedy that's effective for hot flashes -- but, he says, "natural is not better for lots of women. In terms of atrophy in the pelvic floor and vaginal tissues, a lifelong sentence of painful intercourse and bleeding and bladder infections, accelerated uterovaginal prolapse, accelerated osteoporosis, accelerated cardiovascular disease-the female human body runs badly without estrogen, and people who say it's nature's way are sentencing women to a miserable last 30 years of their lives.
"Natural approaches are great, but there's nothing like estrogen to maintain the health of the estrogen-dependent organs: the bladder, the vaginal mucosa, the bones and the cardiovascular system." Not only that, he says, estrogen seems to act as a kind of protective mantle against heart disease; without it, he tells patients, "you have assumed the heart attack risk of a man."
It's not clear that ERT does indeed increase the risk of cancer (potential risks can be reduced by also taking synthetic progesterone, another female hormone); however, women who have had breast cancer, or who have high blood pressure or blood-clotting problems, should not take it.
Women with gallbladder or cholesterol problems, on the other hand, can take ERT via a transdermal patch, which delivers the estrogen directly to the bloodstream, bypassing the liver.
Certainly any woman considering ERT should discuss it fully with her doctor. Some physicians may recommend it be taken only for a certain period of time -- six months, say, to one or two years -- while others recommend it only for women going through a particularly difficult passage.
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