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.
Atrophic vaginitis
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.
Vaginal prolapse
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
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.
