What are the changes that occur in the female genitourinary system among the elderly?

According to the North American Menopause Society, up to 60% of postmenopausal women experience symptoms of genitourinary syndrome of menopause (GSM), which directly impacts the genitourinary system. Understanding what are the changes that occur in the female genitourinary system among the elderly can help manage these often progressive symptoms and improve overall quality of life.

Quick Summary

This article explores the physiological and anatomical changes in the female reproductive and urinary tracts during aging. It covers the effects of declining estrogen, detailing impacts on the bladder, pelvic floor, and vaginal tissues. Information is provided on common conditions like incontinence and increased UTIs, outlining causes and potential management strategies.

Key Points

• Estrogen Decline is the Core Cause: The primary driver of age-related genitourinary changes is the significant drop in estrogen levels after menopause, causing a spectrum of symptoms known as GSM.

• Vaginal Atrophy and pH Changes: Low estrogen leads to thinning, drying, and inflammation of vaginal tissues (atrophy), and a shift to a more alkaline pH, increasing the risk of infections and causing painful intercourse.

• Bladder Capacity and Muscle Changes: The bladder wall becomes stiffer and less elastic, reducing its capacity and leading to increased urinary frequency and urgency, particularly at night.

• Weakened Pelvic Floor Muscles: The support muscles for the bladder and pelvic organs weaken with age, which can cause urinary incontinence, a condition affecting up to 75% of women over 65.

• Increased Risk for UTIs and Prolapse: Weakened muscles, incomplete bladder emptying, and a less protective vaginal microbiome increase susceptibility to recurrent urinary tract infections (UTIs) and pelvic organ prolapse.

• Treatments Are Available: Options range from non-hormonal lubricants and moisturizers to localized estrogen therapy and pelvic floor exercises to manage symptoms effectively.

As women age, particularly during and after menopause, a cascade of hormonal and structural changes affects the genitourinary system. Declining estrogen levels are the primary catalyst for these transformations, impacting everything from tissue elasticity to the vaginal microbiome. The collective term for many of these symptoms is Genitourinary Syndrome of Menopause (GSM), which highlights the interconnectedness of the lower urinary tract and vulvovaginal tissues. These changes can lead to bothersome symptoms that affect daily life and intimacy, but effective treatments and management strategies are available.

Hormonal and Tissue Changes in the Genitalia

Menopause, marked by a drop in estrogen, significantly alters the vulvovaginal environment. Before menopause, high estrogen levels support thick, elastic, and moist vaginal tissues with a protective acidic pH. Postmenopause, this changes significantly:

• Vaginal Atrophy: Vaginal walls thin, dry, and lose elasticity. This can cause irritation, burning, and painful intercourse (dyspareunia). The vaginal canal may also shorten.
• Changes to the Vulva: External genital tissues can thin and shrink due to lost volume and elasticity, potentially causing irritation.
• Shift in Vaginal pH and Microbiome: Reduced estrogen decreases protective lactobacilli, making the pH more alkaline and increasing susceptibility to infections like yeast and bacterial vaginitis.

Urinary System Modifications

The urinary and reproductive systems share embryonic origins and are sensitive to estrogen changes. Decreasing estrogen thins the lining of the urethra and bladder.

• Reduced Bladder Capacity: The bladder wall loses elasticity with age, reducing its capacity and leading to increased frequency and urgency, especially at night (nocturia).
• Weaker Bladder and Pelvic Floor Muscles: Muscles supporting the bladder weaken, making it harder to hold urine or empty the bladder fully. This muscle weakness contributes to incontinence.
• Increased Risk of UTIs: The altered vaginal microbiome and incomplete bladder emptying create an environment for bacteria, increasing the risk of recurrent urinary tract infections.

Weakening Pelvic Support

The pelvic floor's supportive structures also weaken. Ligaments and fascia lose tone and elasticity due to reduced estrogen and aging.

• Pelvic Organ Prolapse: Weakened muscles can no longer support pelvic organs, allowing the bladder (cystocele), uterus (uterine prolapse), or rectum (rectocele) to descend into the vagina. This can cause pressure and further urinary issues.

Lifestyle and Environmental Factors

Other factors can worsen genitourinary symptoms in older women:

• Smoking: Further decreases estrogen and accelerates tissue aging.
• Obesity: Adds pressure on pelvic floor muscles, worsening incontinence and prolapse.
• Medical Conditions: Diabetes and neurological disorders can affect bladder control.
• Surgical History: Past surgeries like hysterectomy can impact genitourinary structures.

How the Genitourinary System Changes with Age

Feature	Younger Women (Premenopausal)	Elderly Women (Postmenopausal)
Hormone Levels	High estrogen and progesterone.	Low estrogen and progesterone.
Vaginal Tissue	Thick, elastic, well-lubricated with protective rugal folds.	Thin, dry, less elastic; vaginal canal may shorten and tighten.
Vaginal pH	Acidic (2.8-4.0), supporting a healthy Lactobacillus microbiome.	More alkaline (>4.5), which alters the microbiome and increases infection risk.
Bladder Capacity	Optimal capacity and elasticity.	Reduced capacity due to stiffer walls.
Bladder Control	Stronger pelvic floor and bladder muscles.	Weaker pelvic floor and detrusor muscles, leading to incontinence.
UTI Risk	Lower due to optimal tissue health and microbiome.	Higher due to thinned tissues and altered flora.
Pelvic Support	Strong pelvic floor and fascial support.	Weakened support, increasing the risk of pelvic organ prolapse.

Management and Treatment Options

• Vaginal Moisturizers and Lubricants: Non-hormonal options for mild vaginal dryness.
• Topical Estrogen Therapy: Localized estrogen creams, tablets, or rings for persistent atrophic changes.
• Oral Medications: SERMs like ospemifene for painful intercourse related to GSM.
• Pelvic Floor Physical Therapy: Strengthening exercises (Kegels) and physical therapy improve incontinence and prolapse symptoms.
• Surgical Intervention: May be necessary for severe prolapse or incontinence.
• Antibiotics: For recurrent UTIs, while addressing root causes.

Conclusion

Changes in the female genitourinary system among the elderly are often progressive consequences of reduced estrogen after menopause. These include vaginal atrophy, microbiome shifts, weakened pelvic floor support, incontinence, prolapse, and recurrent infections. While common, these symptoms can be managed. Consulting a healthcare provider can lead to an effective plan, including lubricants, hormonal therapies, or physical therapy. Understanding these changes helps women maintain a good quality of life.

Visit The Menopause Society for more information and resources on managing menopausal symptoms.

Frequently Asked Questions

What is Genitourinary Syndrome of Menopause (GSM)?

GSM is a medical term that describes the collection of symptoms affecting the vulvovaginal and lower urinary tract, caused by low estrogen levels during and after menopause. Symptoms include vaginal dryness, burning, itching, dyspareunia (painful intercourse), urinary urgency, and recurrent UTIs.

Why does vaginal dryness occur after menopause?

After menopause, a significant drop in estrogen levels causes the vaginal tissues to become thinner, drier, and less elastic. This condition, known as vaginal atrophy, results in decreased natural lubrication, leading to dryness and potential discomfort.

How does aging impact bladder control in women?

Aging can weaken the muscles supporting the bladder and pelvic floor. The bladder itself loses elasticity and can't hold as much urine. These factors contribute to urinary incontinence, which can manifest as an urgent need to urinate or leakage with physical pressure like coughing.

Are urinary tract infections (UTIs) more common in older women?

Yes, UTIs are more common in older women for several reasons. Changes in the vaginal microbiome due to lower estrogen and the tendency for the bladder to not empty completely allow bacteria to multiply more easily, increasing infection risk.

What is pelvic organ prolapse?

Pelvic organ prolapse occurs when weakened pelvic floor muscles and ligaments no longer adequately support the pelvic organs. This can cause the bladder, uterus, or rectum to shift from their normal position and bulge into the vagina, creating a feeling of pressure.

Can Kegel exercises help with genitourinary changes?

Yes, strengthening the pelvic floor muscles through exercises like Kegels can help improve bladder control and support pelvic organs, which can alleviate symptoms of urinary incontinence and mild prolapse.

Is it normal to have these symptoms, and should I see a doctor?

While common, these symptoms are not an inevitable or untreatable part of aging. You should consult a healthcare provider, as effective management strategies and treatments exist, and some symptoms could indicate a more serious condition.