Lately I have heard more and more women ask about incontinence that only occurs at certain times of their cycle. For some it is the week before their period starts and for others it is only during their period that they notice increased incontinence. Unfortunately, the research on incontinence and a woman’s monthly cycle is seriously lacking. Luckily, we do have one study that gives a little insight into cyclical incontinence. The study showed 41% of women notice their incontinence is cyclical and of those women 42% notice symptoms just before their period and 36% of women notice increased symptoms during their period.3
Leaking Before & During your Period
While we need more research on cyclical incontinence, it can be helpful to look at the research we do have—specifically increased incontinence during menopause. Menopause, like the premenstrual time frame, is when the natural production of estrogen declines. In fact, estrogen levels are lowest right before, during and immediately after the period. These low estrogen levels can decrease ligament laxity and increase ligament stiffness.4 What this means is that approximately a week before menses occurs there is a drop in estrogen which is believed to decrease the strength of the urethra, the tube that connects that bladder to the urinary meatus (how we get urine from the bladder to the outside).
The human body is an amazing thing - it changes and adapts to the hormones that our body naturally releases and the pelvic floor is no different. In fact, the pelvic organs as well as the surrounding connective tissues are all estrogen-responsive, meaning the tissues respond and adapt to fluctuations in estrogen.2 We commonly see this effect in women with stress incontinence who are pre-menopausal due to lower levels of estradiol being produced.1 With the decrease in estrogen, the pelvic floor and surrounding ligaments are unable to appropriately adapt to changes in intra-abdominal pressure, causing increased incontinence due to the decreased strength, increased stiffness and decreased ligament laxity.
These natural fluctuations in estrogen may also affect the orientation of the cervix. The change in orientation can affect the sphincter of the urethra, or the ability to start/stop the flow of urine efficiently and effectively. This helps us better understand that increased incontinence before and during our periods may be due to the decrease in estrogen which changes the pressure around the urethra causing it to lose elasticity and not being able to fully close and stop the flow of urine.
Leaking When Using a Tampon or Menstrual Cup
By inserting a tampon or a menstrual cup we are naturally altering intra-abdominal pressure (IAP). Altering our ability to appropriately create and maintain IAP, we alter our body’s ability to properly adapt to the environment. This is done through either hypertonic (tight) muscles that are unable to properly relax and therefore unable to create a strong contraction because it is always contracting or hypotonic (reduced tone) and are not able to create a strong contraction.
Leaking only when using a tampon or menstrual cup may also be a sign of a cystocele (bladder prolapse) masking stress urinary incontinence. A cystocele can cause the urethra to kink and actually block the flow of urine. By using a tampon, it acts as a pessary to reduce the cystocele and unkink the urethra allowing for the proper flow of urine. Unfortunately, in some cases, this proper flow of urine reveals incontinence that was previously hidden by the cystocele.
What can we do about it?
As there are structural changes taking place, it may be a good idea to re-frame your workout based on your cycle. If you are one of those that notices increased incontinence prior to your period or during, it may be a good idea to transition to lower impact exercises or focus more on the rest and recovery phase of health. Now that is not to say that you can’t exercise, it may just be a good idea to swap out double unders or box jumps for BIRTHFIT functional progressions or unilateral farmers carry or even Russian kettlebell swings.
As with any leaking or incontinence issue, it is important to be evaluated by someone with extra training in pelvic floor health. That way a care plan can be created based on your specific needs. To find one in your area reach out to your BIRTHFIT Regional Director for local resources or check the Herman & Wallace Certified Pelvic Rehabilitation Practitioners or the list of APTA’s Women's Health PT.
2. Tzur T1, Yohai D1, Weintraub AY1. The role of local estrogen therapy in the management of pelvic floor disorders. Climacteric. 2016 Apr;19(2):162-71. doi: 10.3109/13697137.2015.1132199. Epub 2016 Feb 2.
4. Reese M, Casey E. Hormonal Influence on the Neuromusculoskeletal System in Pregnancy. Musculoskeletal Health in Pregnancy and Postpartum: An Evidence-Based Guide for Clinicians. January 2015. (pp.19-39).