Perimenopause incontinence: why leaks start in your 40s and what helps

Perimenopause incontinence is bladder leakage that starts or gets worse in the years before your last period, usually in your 40s. Falling and swinging estrogen, a pelvic floor that has lost some strength since childbirth, weight gain, coughs and poor sleep all add up, and leaks show up when you sneeze, laugh, run or reach the front door. It is common and it is treatable: pelvic floor muscle training and bladder training are the first treatments guidelines recommend, and many women's leaks get better, not worse, after the transition.

Below: what perimenopause does to the bladder, what a large US study found about who starts leaking and when, how to tell which kind of leak you have, whether it goes away, a six-week way to start at home, where hormones fit in, and when to see a doctor first.

Is bladder leakage a sign of perimenopause?

It can be one of them. Perimenopause is the run-up to menopause, when the ovaries make less estrogen and make it less evenly. Mayo Clinic says it usually starts in a woman's 40s, though it can start in the late 30s, and lasts about four years on average, sometimes only months and sometimes ten years. Menopause itself is one day: 12 months after your last period, at an average age of about 51 in the US.

The signs most women notice first are changes to periods (shorter or longer cycles, heavier or lighter bleeding, skipped months), hot flushes, night sweats, poor sleep, mood changes and vaginal dryness. Bladder changes sit in the same list:

• Small leaks when you cough, sneeze, laugh, lift or jump.
• Sudden urges that are hard to put off, with or without a leak.
• Going to the toilet more often, day and night.
• More urine infections than you used to get.
• Burning or soreness that isn't an infection, from drier, thinner tissue.

Leaks on their own don't prove you're in perimenopause, and they aren't only hormones. If your periods have changed and leaks have started at the same time, though, the two are often linked.

Why perimenopause can cause leaks

Staying dry depends on the urethra (the tube you pee through) staying shut while pressure in your belly rises. Several things help it stay shut: the pelvic floor muscles under it, the support around it, and the cushion of tissue and blood vessels in its lining. Perimenopause can weaken each of them a little.

Estrogen and the tissues

The lining of the urethra, the base of the bladder and the vagina all have estrogen receptors. As estrogen falls, those tissues get thinner, drier and less springy, and the urethra seals less well. The Menopause Society calls the group of vaginal, bladder and urinary changes the genitourinary syndrome of menopause (GSM). A 2020 review estimated that 50 to 70% of postmenopausal women have at least some GSM symptoms, and some start well before the last period.

The pelvic floor itself

Muscle strength falls a little each decade from mid-life, and the pelvic floor is no exception. Many women in their 40s have also had one or more vaginal births, which can stretch or injure the muscles and their nerves. A floor that coped fine at 30 can start to lose to a hard sneeze at 45.

Everything else that changes at the same time

• Weight. Many women gain weight around the waist in midlife, and extra weight presses on the bladder. In the US SWAN study, a high starting weight and weight gain over the years were both linked to developing more frequent leaks.
• Sleep. Night sweats wake you, and once awake you notice your bladder and go. Night trips rise.
• Drinks. More coffee to get through tired days, and more water for hot flushes, both send you to the toilet more.
• Coughs and lifting. A long cough, a new gym habit, or lifting a parent or grandchild all push down on the pelvic floor.
• Mood. SWAN also found worsening anxiety was linked to developing more frequent leaks. Stress and urgency feed each other.
• New conditions. Diabetes, which becomes more common in midlife, was linked to new leaks in the same study, and some medicines (water tablets, some blood pressure and sleep drugs) can add to them.

What a large US study found

The Study of Women's Health Across the Nation (SWAN) followed thousands of midlife women of different backgrounds year after year as they went through menopause. One paper (Waetjen and colleagues, Obstetrics & Gynecology, 2009) looked at women who were dry at the start and tracked who began to leak.

Two things stand out. First, perimenopause is when leaks most often start; the years after menopause saw fewer new cases. Second, the authors found the menopause stage was linked to new leaks that happen monthly, but not to leaks happening weekly or more. In their words, only infrequent incontinence was attributable to the perimenopause. Frequent, bothersome leaks were tied more to weight, weight gain, diabetes and anxiety than to the hormones alone.

That matters for what you do about it. If your leaks are frequent, the hormones are probably not the whole story, and the things you can change (the pelvic floor, the bladder habit, weight, drinks, coughs) are where to start.

Which kind of leak do you have?

Most help depends on the kind. NICE, the UK's clinical guideline body, asks doctors to sort leaks into three groups:

In perimenopause, stress leaks tend to be the first to show up, and urgency often joins them later as the tissues change. SWAN found the same pattern of risk for both kinds. If you can't tell, keep a bladder diary for three days: each trip, each leak and what you were doing, each drink. The pattern is usually clear on paper.

If your leaks are mainly urges, our guide on a sudden urge to pee you can't hold has the steps for the moment it hits.

Does perimenopause incontinence go away?

Often it gets better, sometimes on its own, but it is not something to just wait out. Here's what the evidence says:

• Leaks come and go. A related SWAN paper (Waetjen and colleagues, 2008) followed women's leaks from year to year and found that improving, and stopping altogether, were common, not only worsening. Leaks that started with a bad cough, a heavy year or a burst of weight gain often eased when those did.
• New cases fall after menopause. In the table above, postmenopausal women were about half as likely to start leaking monthly as women before perimenopause.
• The tissue changes don't fix themselves. GSM, the thinning and dryness, tends to stay or slowly get worse after menopause unless it's treated. If your leaks come with dryness, soreness or repeat infections, they're less likely to fade on their own; see the hormone section below.
• Muscle strength doesn't come back on its own. If the pelvic floor has weakened, it stays weaker until you train it. The good news: it is a muscle, and muscles respond to training at any age.

So the honest answer: some perimenopause leaks settle, but the ones that come from a weaker floor or thinner tissue usually need you to do something. Training now also sets you up for the years after, when the floor keeps losing a little strength each decade.

What helps perimenopause leaks

1. Pelvic floor muscle training

This is the first treatment for stress and mixed leaks. NICE recommends a supervised programme of at least 3 months, with at least 8 contractions three times a day. A 2018 Cochrane review of 31 trials found women with stress leaks who did pelvic floor training were about 8 times more likely to report being cured than women who didn't. That's a group average, not a promise for one person, but it's why guidelines put it first.

The catch is doing it right: many women push down instead of lifting, or hold their breath. Our guide on how to do Kegels correctly has five ways to check.

2. Bladder training

For urges and frequency: going by the clock instead of the urge, and stretching the gap by 15 minutes at a time. NICE asks for at least 6 weeks. The full plan is in our bladder training schedule.

3. The Knack

A quick, hard squeeze of the pelvic floor just before and during a cough, sneeze, laugh or lift. It's a skill you can start using in the first week, before the muscles are stronger. Read more in leaking urine when you sneeze or cough.

4. Weight, if you have some to lose

NICE advises women with a BMI over 30 to lose weight for leaks. In the PRIDE trial (Subak and colleagues, New England Journal of Medicine, 2009), overweight women who lost about 8% of their weight over six months had 47% fewer weekly leaks, against 28% fewer in the group that got only general advice.

5. Drinks

• Drink enough: the NHS suggests 6 to 8 glasses of fluid a day. Drinking less makes urine stronger, which can irritate the bladder.
• Cut caffeine down, or swap to decaf for two weeks to see if it helps. NICE suggests trying a cut in caffeine for urge and frequency.
• Notice alcohol and fizzy drinks; some women find they set off urges.
• Have most of your drinks before late afternoon if you wake at night to pee.

6. Treat the things that push down

A cough that won't go, constipation that has you straining, or heavy lifting with held breath all load the pelvic floor many times a day. Treating a chronic cough, eating enough fibre and breathing out as you lift take pressure off.

A six-week way to start at home

A simple start that covers both kinds of leak. Do it most days; missing a day doesn't undo anything.

Change shows up slowly. Most women notice it somewhere between 6 and 12 weeks, and NICE asks for at least 3 months before judging pelvic floor training. Our guide on how long Kegels take to work explains what to expect each month. For a full daily session, see our 10-minute pelvic floor routine.

If you'd rather see where your leaks fit before you start, the free 1-minute check asks when they happen and shows why Kegels alone often don't help.

Leaks at night in perimenopause

Night sweats and broken sleep often come with more trips to the toilet at night. Some are the bladder; some are simply waking for another reason and then noticing it. A few things to look at:

• Note in your diary whether you woke because you needed to pee, or woke from a sweat or noise and then went.
• Have most drinks before late afternoon, and limit caffeine and alcohol in the evening.
• If your ankles swell during the day, put your feet up for an hour in the evening; fluid stored in the legs comes back to the bladder when you lie down.
• Go once more just before bed.
• Waking twice or more every night to pee is worth raising with a doctor: it can be linked to sleep apnoea, diabetes, heart or kidney problems, or medicines.

Treating night sweats themselves, which is often part of a menopause appointment, can cut night waking too.

Does HRT help perimenopause incontinence?

It depends on which kind of hormone treatment:

• Vaginal estrogen (a cream, tablet, pessary or ring used in the vagina) treats the thinning and dryness of GSM. NICE recommends offering it to postmenopausal women with vaginal atrophy who have urgency or an overactive bladder, and the American urology guideline on repeat infections recommends it for peri- and postmenopausal women who keep getting UTIs. The dose is small and stays mainly in the local tissue.
• Systemic HRT (tablets, patches, gels) is used for hot flushes, night sweats and other symptoms. It is not a treatment for leaks: NICE advises against it for urinary incontinence, and in the large Women's Health Initiative trials, women on oral HRT were more likely to develop leaks, not less. That's no reason to avoid HRT for your other symptoms; just don't expect it to fix your bladder.

Hormones are a conversation to have with your doctor, who will look at your own history. They work best alongside the pelvic floor and bladder training above, not instead of them.

When to see a doctor first

Most perimenopause leaks are safe to start working on at home. See a doctor before or alongside, if you have:

• Pain or burning when you pee, fever, or cloudy or smelly urine (a possible infection).
• Any blood in your urine.
• Bleeding after sex, between periods, or any bleeding a year or more after your last period.
• A bulge, heaviness or dragging feeling in the vagina, which can be a prolapse.
• A weak or stop-start stream, straining, or feeling you never empty.
• Leaks that came on suddenly, are constant, or happen without you noticing.
• New thirst, weight loss or tiredness alongside going more often.
• Bloating most days for 3 weeks or more, with feeling full quickly or needing to pee more often.
• Numbness around your bottom or genitals, new trouble peeing, or weak legs, with back pain. Get urgent care the same day.

Also worth asking for: a referral to a pelvic floor physical therapist or a continence nurse. NICE wants pelvic floor training to be supervised, and an internal check of how the muscles work can find problems you can't feel yourself, such as a floor that's too tight rather than weak. If you have pelvic pain, pain with sex, or trouble starting to pee, read tight pelvic floor symptoms before you start squeezing.

Perimenopause, menopause and what comes next

Perimenopause leaks and post-menopause leaks share most causes and most treatments. For what changes after the last period, the role of vaginal estrogen and night-time trips in later years, read bladder leakage and menopause. If your main symptom is a feeling of pressure or fullness rather than leaks, see bladder pressure after menopause. And if you're past 50 and want exercises built for knees, hips and backs that aren't what they were, see pelvic floor exercises for women over 50.

Frequently asked questions

Can perimenopause cause incontinence?

It can add to it. Falling estrogen thins the tissue that helps seal the urethra, and it arrives at the same age as other changes: weaker muscles, weight gain, poor sleep. In the SWAN study, women in perimenopause were more likely to start leaking monthly than women before it.

At what age does perimenopause incontinence start?

Usually in the 40s, when perimenopause usually begins, though it can start in the late 30s. Leaks can also start at any age for other reasons, such as childbirth.

Will my bladder go back to normal after menopause?

Some women's leaks ease, and new leaks are less common after menopause than during perimenopause. But a weaker pelvic floor and thinner tissue don't fix themselves; training and, where it fits, vaginal estrogen are what make the difference.

Can perimenopause cause a frequent need to pee?

Yes. Thinner, more sensitive tissue in the bladder and urethra can make you feel the need to go sooner and more often, and broken sleep adds night trips. Infections and diabetes cause the same thing, so tell a doctor if it's new.

Are Kegels enough for perimenopause leaks?

For stress leaks, a proper programme (not a few squeezes now and then) is the first treatment and works for many women. For urge leaks, add bladder training. For dryness and repeat infections, talk to a doctor about vaginal estrogen.

Is it normal to leak in your 40s?

It's common, but common isn't the same as something you have to live with. Leaks in your 40s respond well to treatment, and the earlier you start, the less they shape your days.

Start this week

Start a 3-day bladder diary today and use the Knack before your next cough or sneeze. Then pick the week 1 squeezes above and do them before you get up and before you sleep. To see in one minute where your leaks fit and what a daily plan built week by week looks like, take the free 1-minute check. For more on leaks, urges and the pelvic floor after 40, see all our pelvic floor guides.

Sources: Mayo Clinic, Perimenopause: symptoms and causes. Waetjen L.E. et al., Association between menopausal transition stages and developing urinary incontinence, Obstetrics & Gynecology, 2009 (SWAN). Waetjen L.E. et al., Factors associated with worsening and improving urinary incontinence across the menopausal transition, Obstetrics & Gynecology, 2008 (SWAN). Angelou K. et al., The genitourinary syndrome of menopause: an overview of the recent data, Cureus, 2020. The Menopause Society, The 2020 genitourinary syndrome of menopause position statement. NICE guideline NG123, Urinary incontinence and pelvic organ prolapse in women: management, 2019. Dumoulin C., Cacciari L.P., Hay-Smith E.J.C., Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women, Cochrane Database of Systematic Reviews, 2018. Subak L.L. et al., Weight loss to treat urinary incontinence in overweight and obese women, New England Journal of Medicine, 2009. AUA/CUA/SUFU guideline, Recurrent uncomplicated urinary tract infections in women, 2019. Hendrix S.L. et al., Effects of estrogen with and without progestin on urinary incontinence, JAMA, 2005 (Women's Health Initiative). NHS, Water, drinks and your health. NHS, Ovarian cancer symptoms. NHS, Cauda equina syndrome. This guide is education, not medical advice.