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IC, Hormones, Perimenopause and Menopause

• The Menstrual Cycle
  
• Symptoms Vary In IC Patients
  
• Premenstrual Syndrome (PMS) and Chronic Conditions
  
• Perimenopause and Menopause
  
• Physical Changes that Affect the Bladder During Perimenopause
  
• Hormone Replacement
  
• Estrogen
  

Research shows that hormonal changes affect systemic conditions with flare-ups and remissions such as IC, fibromyalgia (FMS), chronic fatigue syndrome (CFS), vulvodynia, multiple chemical sensitivity (MCS), irritable bowel syndrome (IBS), Sjogren's syndrome and lupus.

Hormonal imbalance has been speculated as a possible cause of IC. Whether IC is, or is not caused by a hormonal imbalance in some patients, hormones certainly affect IC symptoms during the monthly menstrual cycle, during pregnancy, and during perimenopause and menopause. Understanding how hormones affect the bladder is very important.

The Menstrual Cycle

The first day of the menstrual period is also day one of the menstrual cycle. Although both estrogen and progesterone are at their lowest levels on day one, estrogen begins to rise and continues to rise after menstruation. The rise in estrogen levels thickens the uterus in preparation for fertilization. The rise in estrogen also thickens the bladder lining during this time. Estrogen levels reach their peak at ovulation, about day 14 of the cycle.

During the first two weeks of the menstrual cycle only a small amount of progesterone is present. However, after the egg is released during ovulation, estrogen levels quickly decline and progesterone levels begin to rise in preparation for pregnancy. Although estrogen levels also begin to rise again, they stay at a lower level than that of the first half of the menstrual cycle. During this second half of the menstrual cycle estrogen and progesterone levels reach a peak around the same time, about the third week of the menstrual cycle. If the egg released during ovulation has been fertilized the progesterone levels remain high. If the egg has not been fertilized both estrogen and progesterone production diminish quickly. The decline of progesterone levels causes shedding of the endometrium (the uterine lining), which begins a new menstrual cycle.

Symptoms Vary In IC Patients

There is no set pattern for symptoms in IC patients. There are patients who experience an increase in swelling, pressure, pain, and frequency when estrogen levels are highest. This is believed to happen because estrogen increases mast cell secretion, therefore increasing inflammatory reactions. There are patients who feel better when their estrogen levels are high. Experts believe that IC patients may benefit from the increase in the thickness of the bladder lining and the lack of progesterone during this time.

Some IC patients say they feel best and experience less symptoms during their menstrual period when hormone levels are low. However, other patients experience bladder pain during their periods, and almost all IC patients complain of IC symptoms a few days prior to the onset of bleeding. A number of IC patients also report pain just after a period and/or around ovulation. Experts may disagree about the effects hormones have on the IC bladder, but what they consistently agree upon is that the bladders of IC patients react to the rise and fall of hormone levels.

Premenstrual Syndrome (PMS) and Chronic Conditions

PMS occurs during the second half of the menstrual cycle when progesterone levels are at their highest. Common symptoms include fluid retention, irritability, headaches, backache, and sometimes, abdominal pain. The lower estrogen levels and high progesterone levels make some IC patients more susceptible to bladder symptoms, constipation (especially during perimenopause when bowel activity slows down), abdominal pressure, stiff muscles and fatigue. Sensitivities to the environment and to certain drugs may also be intensified during PMS.

Perimenopause and Menopause

If you watch TV you may have seen an ad for natural hormone replacement with a mother and her "30 something" daughter. The mother explains how hormonal changes can begin in a woman's early thirties. The daughter in the ad may not notice the changes she is going through at such a young age (yes, thirty is young!), but if she had IC she would more than likely feel those subtle changes.

Perimenopause begins when a woman's estrogen levels start to decline. Although this decline usually begins in a woman's late 30's or early 40's, some women can begin to experience perimenopausal symptoms in their early 30's. The average length of perimenopause is five to ten years, but it can take longer.

Menopause is believed to occur between the age of 45 and 55, with the average age at 51. Menopause can happen quickly or take two to four years (some women experience hot flashes into their 70's). When a woman has had no menstrual period for 12 months and blood tests confirm the decline of estrogen, menopause is considered official. A woman is no longer in perimenopause. Instead, she is now in postmenopause.

Symptoms during perimenopause vary woman to woman because the approach to menopause is so individual. Fluctuations of estrogen create hormonal swings which in turn can cause night sweats, waking episodes, insomnia, hot flashes, chills, palpitations, lighter, heavier, or irregular periods, complexion problems, depression, and troubles with memory and concentration.

Women in early perimenopause can experience night sweats, insomnia, painful PMS, and constipation. As hormone levels begin to drop, symptoms can change. Blood tests are used to determine hormone levels.

Physical Changes that Affect the Bladder During Perimenopause

The smooth muscle in the bladder, urethra and vagina lose tone and strength as estrogen levels decline. Because the bladder lining, the nerves, blood vessels, and muscles that govern urinary function are all affected by estrogen, the decline of estrogen during perimenopause and menopause increases sensitivity to pain and susceptibility to bladder problems.

When there is a decrease in blood flow and lubrication, the urethral, bladder and vaginal tissue become thinner, drier, less resilient, and more susceptible to inflammation. These various changes also leave the bladder vulnerable to infection and can cause symptoms such as urgency, frequency, burning, and sometimes, mild incontinence (IC does not lead to incontinence).

As IC patients begin to reach menopause their IC symptoms can also change. Patients who are used to feeling relief upon urination (due to the lack of blood flow when voiding) may experience some burning in the urethra instead. Patients in early menopause may begin to notice cramping in their pelvic floor around ovulation, right before or after their menstrual periods. Patients with endometrosis, or irritable bowel syndrome (IBS) may experience more pain from inflammation and built-up scar tissue as hormones begin to decline. In general, women with injured muscles and ligaments from surgeries, childbirth or low back problems may experience compounded weakness and bladder problems. Pressure on pelvic veins can cause painful varicose veins, pelvic and leg pain. Perimenopause is a time to keep back muscles strong, use good support while sitting and avoid lifting heavy objects (a good idea for IC patients of all ages).

Hormone Replacement

There are standard blood tests to determine hormone levels and the appropriate dose of hormone replacement, but finding the right time to begin replacement and the correct level or type of hormone replacement is often "trial by error" for patients with IC. * Patients need to work with gynecologists or naturopaths who specialize in alternative medication (if using supplements) to regulate hormonal balance, because everything changes during menopause, including IC.

Doctors may not be aware that there are IC patients who cannot tolerate estrogen that is opposed with progesterone, but usually will understand if their patients explain that progesterone increases symptoms in women with other conditions, such as migraine headaches. Alternative doctors or naturopaths who promote natural progesterone believe that natural progesterone does not provoke the side effects of synthetic progestins. However, plant progesterones are known to increase urinary frequency in women without IC.

Both natural progesterone and progestins produce a similar anti-growth factor in the uterus like that of the body's own progesterone. Women who take estrogen without progesterone risk cell build up in the lining of the uterus, which may lead to endometrial cancer. A woman's doctor must evaluate her personal
health profile, as well as her family history when prescribing hormone replacement therapy.

Estrogen

Estrogen plays a role in the management of many chronic conditions. The effects of estrogen seem to fight pain in a variety of conditions. There are many IC patients who avoid severe bladder, muscle and joint pain and IBS symptoms with estrogen replacement. However, there are IC patients who experience bladder pain with estrogen replacement because of the increase of mast cell secretion. What works depends on the individual patient.

Today's information on estrogen is disturbing. Researchers know now that although estrogen improves some cardio-vascular risk factors, it does not lower stroke risks. Women who have been diagnosed with heart disease are being advised to avoid taking estrogen. Also, the fact that breast cancer is most prevalent in developed nations, where women are treated with hormone replacement, is not good news for women who use estrogen.

Although I am not at risk for stroke, heart disease or breast cancer, I have recently reduced my estrogen dosage. I am now experiencing hot flashes and waking episodes at night, but my IC symptoms have not worsened. I plan to continue with the lower dose of estrogen for a few years after my menopause is considered official. Then I will see where I stand, and if I need a little estrogen for my bladder I will definitely continue to use it. I can honestly say that my IC symptoms have really improved with menopause and they would not have without estrogen replacement. But as always, IC patients are all different. What helps some makes others symptomatic.

For more information about hormone replacement choices and menopause management without hormones refer to our Patient to Patient: Managing IC & Related Conditions book, now on sale in the ICN Shop!

* The Menopause Home Test kit has recently been developed.

Women are encouraged to discuss the results of their tests with their doctors.