The Vicious Cycle of Menopause: A Narrative Review of the Interplay Between Urinary Incontinence, Mood Disturbances, and Sleep

Abstract

Background: The menopausal transition is a period marked by the significant co-occurrence of urinary incontinence (UI) and mood disturbances (MD), such as depression and anxiety, which substantially impair quality of life. While often attributed separately to hormonal decline, the underlying mechanisms for their comorbidity are not fully explained by estrogen deficiency alone. A growing body of evidence suggests a complex interplay, potentially mediated by other factors, with sleep disturbance emerging as a critical candidate. Methods: This narrative review synthesized literature identified through a comprehensive search of PubMed, Scopus, and PsycINFO databases. The search strategy combined keywords related to menopause, urinary incontinence, mood disorders, and sleep. We included observational studies, clinical trials, and relevant reviews published in English, focusing on peri- and postmenopausal women. The analysis was structured to evaluate the bidirectional relationships between UI, MD, and sleep, and to assess the evidence for sleep’s role as a mediating factor. Results: The synthesis of evidence reveals strong, bidirectional relationships between all elements of the proposed "menopausal triad." UI, particularly through nocturia, directly fragments sleep architecture, leading to decreased sleep efficiency and reduced restorative slow-wave sleep. This sleep disruption, in turn, provokes neurobiological changes (e.g., amygdala hyperactivity, prefrontal cortex dysfunction) and HPA-axis dysregulation that predispose to and exacerbate MD. Concurrently, MD heightens the perception of UI severity through somatic awareness and catastrophizing, while also reducing adherence to self-management strategies. Critically, sleep disturbance functions as a central mediator, creating a self-perpetuating cycle where UI worsens sleep, which in turn worsens mood, ultimately increasing the burden and perception of UI. Conclusion: This review establishes that UI and MD in midlife women are intricately linked through the mediating pathway of sleep disturbance. The "menopausal triad" model provides a transformative framework for clinical practice, moving beyond a siloed approach. It mandates integrated assessment, where screening for all three components is essential, and promotes treatment strategies that target sleep improvement as a powerful leverage point to break the vicious cycle. This holistic approach is vital for allied health professionals to improve the overall quality of life for women navigating midlife.