Blog cover Causes of Urinary Incontinence During Perimenopause

Causes of Urinary Incontinence During Perimenopause

Hi everyone! In today’s article we are going to talk a bit about Estrogen. Estrogen is the new hot topic in women’s health. We are learning more and more about how estrogen impacts a woman’s body. Estrogen, which declines rapidly during menopause, is responsible for the health of the tissues around our vulva. The terminology for the symptoms of low estrogen impacting pelvic health is genitourinary syndrome of menopause. These symptoms include vaginal dryness and/or burning, urinary symptoms of urgency and/or incontinence, and low sexual desire and function. Today we are going to focus on perimenopause urinary incontinence.

 In this article we will explore:

  • How low estrogen impacts perimenopause urinary incontinence?
  • What exercises best improve perimenopause?

For more information on Urinary Incontinence click here

Low Estrogen

There are estrogen receptors in the vulva and urethra. With normal estrogen levels, the vulva tissue remains healthy and urethra muscle has bulk making it easier to close. However, with the drop in estrogen from perimenopause the vulva tissue will dry and urethral muscle mass decreases. The urethra muscles thin out making it more difficult to fully contract and close the urethra.


This should start with a discussion with your OBGYN. Specific to pelvic health and urinary function, the use of topical estrogen can be helpful to improve muscle bulk of the urethra. The use of topical estrogen needs to be managed due to it’s impact on the surrounding fascia. 


Adding topical estrogen can impact the surrounding fascia making it stretch which limits the connective tissue support for the bladder. In some women, topical estrogen can actually make leakage worse. 

Pelvic floor physical therapists with advanced training in the management of stress urinary incontinence, like the therapists at Optimize Pelvic Health, will be able to help guide the estrogen conversation with your OBGYN.

Weakness of the Urethra Muscle


The urethra muscle has a different nerve input than the nerve going to the deep pelvic floor. Your typical Kegel does not address the strength of the urethra. The nerve going to the urethra is the perineal nerve. The perineal nerve not only gives input into the urethra but also gives input into the outer layer of the pelvic floor. It is difficult to assess urethra strength directly, however we can assess the strength of the outer layer of the pelvic floor. 

To target the outer layer pelvic floor, the focus is on anterior pelvic muscle training. Cues to target these muscles are “nod the clitoris” and “close your vulva”. These cues with help isolate the outer layer pelvic floor muscles which share the same nerve going to your urethra. 

A pelvic floor physical therapist with advanced training, like the therapists at Optimize Pelvic Health, will be able to identify the strength of the outer layer, and help you activate this muscle. Improving the strength of the outer layer pelvic floor will also strengthen the urethra and decrease perimenopause urinary incontinence. 

Stress Management

Stress levels are the foundation of good pelvic health. To maintain pelvic health, your overall stress state should be fairly low. When there is a situation that increases short term stress and anxiety, your body is equipped to respond with limited affect on pelvic health. However, a lot of us are in a consistently heightened stress state. This places an even larger demand on our body (and our pelvic floor) when a stressful situation presents itself. 

At Optimize Pelvic Health, the stress and relaxation nervous system at the foundation of pelvic health. When your body is stressed, it will resist stretching or strengthening. 

What person, especially in the perimenopausal period, is not stressed. 

When our body is stressed, the entire nervous system is irritated, even the nerves going to the bladder. When these nerves are irritated it signals the bladder that you need to pee.  Have you ever noticed in stressful situations you feel like you have to pee more?


We are not going to take your stress away. However, we can bring your relaxation nervous system up to meet the demands of the stress nerves. 

One quick and easy way is a face and scalp massage. Have you ever wondered why a facial feels amazing? The reason is during a facial the sensation nerves, called the trigeminal nerve, in your face are stimulated. These nerves indirectly tell your body to relax by communicating with the vagus nerve, the primary relaxation nerve (more on this later).  A simple face and scalp massage will improve the signal of the trigeminal nerve to speak to the vagus nerve. Or you can say, a pelvic floor physical therapist told you to get a facial. 

Another way to promote relaxation is direct stimulation of the vagus nerve. The vagus is the primary nerve responsible for telling our brain “we are ok”. This nerve exits our skull to travel to various organs in our body. It then goes back up to our brain to tell it “everything is fine.” This is also the reason that when you are stressed you have stomach pain.

My favorite way to stimulate the vagus nerve is called the basic exercise. It originated in osteopathy. It targets the nerve right where it exits the skull.

Basic Exercise for Vagus Nerve
  1. Interlace your fingers.
  2. Place your hands at the base of the skull.
  3. Pull your head gently away from your spine. 
  4. With your eyes ONLY, look to one side. 
  5. Hold it for up to 1 minute or until you have a sigh, yawn, deep breath or double breath. 
  6. Repeat on the other


Urinary incontinence during perimenopause is mostly driven by estrogen. However, strengthening the urethra and improving your relaxation response can improve urinary leakage. Topical estrogen can also be used to minimize the impact perimenopause has on urinary leakage. It’s crazy to think how in our parents and grandparents’ generation, women were put in asylums, given electroshock therapy, a hysterectomy and even a lobotomy for menopause. The word base of hysterectomy is hysteria!! A relic from a time when hysteria was believed to be a disorder solely attributable to women, with the source being the uterus. Meaning a hysterectomy is removing hysteria from a woman. 

At Optimize Pelvic Health, we have specific assessment and treatment strategies to work with those with perimenopausal urinary incontinence. We will be able to tell you the major factors contributing to urinary leakage. When you go to pelvic floor physical therapy, they should be able to tell you how the urethra, stress and estrogen plays a role in your perimenopause urinary leakage.

Share this blog with someone you know who has perimenopause urinary incontinence. 

For more information about causes of urinary leakage.

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