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The mysteries of menopause and urogynecologic health

clinical and scientific gaps

Alperin, Marianna, MD, MS; Burnett, Lindsey, PhD, MD; Lukacz, Emily, MD, MAS; Brubaker, Linda, MD, MS

doi: 10.1097/GME.0000000000001209
Clinical Corner: Invited Review

Objectives: A significant body of knowledge implicates menopausal estrogen levels in the pathogenesis of the common pelvic floor disorders (PFDs). These health conditions substantially decrease quality of life, increase depression, social isolation, caregiver burden, and economic costs to the individuals and society.

Methods: This review summarizes the epidemiology of the individual PFDs with particular attention to the understanding of the relationship between each PFD and menopausal estrogen levels, and the gaps in science and clinical care that affect menopausal women. In addition, we review the epidemiology of recurrent urinary tract infection (rUTI)—a condition experienced frequently and disproportionately by menopausal women and hypothesized to be potentiated by menopausal estrogen levels.

Results: The abundance of estrogen receptors in the urogenital tract explains why the natural reduction of endogenous estrogen, the hallmark of menopause, can cause or potentiate PFDs and rUTIs. A substantial body of epidemiological literature suggests an association between menopause, and PFDs and rUTIs; however, the ability to separate this association from age and other comorbid conditions makes it difficult to draw definitive conclusions on the role of menopause alone in the development and/or progression of PFDs. Similarly, the causative link between the decline in endogenous estrogen levels and the pathogenesis of PFDs and rUTIs has not been well-established.

Conclusions: Innovative human studies, focused on the independent effects of menopausal estrogen levels, uncoupled from tissue and cellular senescence, are needed.

Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA.

Address correspondence to: Linda Brubaker, MD, MS, University of California San Diego, 9500 Gilman Drive, MC 0971, La Jolla, CA 92093. E-mail:

Received 1 July, 2018

Revised 14 August, 2018

Accepted 14 August, 2018

Funding/support: None reported.

Financial disclosures/conflicts of interest: Dr Alperin reports stipends from Renovia, Inc., for serving on the Medical Advisory Board and has received the following grants: NIH/NICHD R01 HD092515 and NIH/NIA R03 AG050951. Drs Burnett and Lukacz report no disclosures. Dr Brubaker reports editorial stipends from JAMA, Female Pelvic Medicine and Reconstructive Surgery, and Up to Date.

© 2019 by The North American Menopause Society.