Age 46, Waking at 2–3 a.m. to Pass Small Amounts of Urine, Blurry Vision, and Knee Pain Needing Repeated Painkillers: When to Check for Diabetes, Using Pain Relievers Safely, and Herbal Women’s Tonics to Watch

From a group of women over 40: waking at 2 a.m., unable to fall back asleep, several trips to the toilet, blurry vision and knee pain

One member in her mid-40s described going to bed at 9 p.m. but waking abruptly between 2 and 3 a.m. and staying awake until morning. She gets up several times a night to urinate, but only a little comes out each time.
Lately her vision is blurry and her body aches, especially her knees, so she takes painkillers again and again. Several other members warned her about herbal women’s tonics and remedies bought without advice.

Short answer: these symptoms may not share a single cause. Frequent small voids point more toward the bladder or sleep than toward diabetes,
but being 46 with blurry vision is reason enough to check blood glucose and see an eye specialist, and daily repeated painkillers deserve a review.
For a detailed look at night-time urination and sleep, read
Waking 2–3 times a night to urinate after 40 and poor sleep

1. Waking at 2–3 a.m. and passing little urine: bladder or sleep?

Direct answer: nocturia falls into three types: too much urine over 24 hours, too much urine only at night, and a bladder that holds less.
Small voids point to the third type, or to waking from poor sleep and then going to the toilet. A 3-day diary helps tell them apart.

Three types of nocturia

A systematic review in European Urology (Cornu 2012)
concluded that the frequency-volume chart is the key clinical tool: it shows whether there is 24-hour polyuria, nocturnal polyuria, or reduced nocturnal bladder capacity.
Each type has different causes and treatments, and untreated nocturia harms quality of life.

What small, frequent voids suggest

Diabetes with high blood glucose usually produces large volumes each time, with thirst throughout the day. Small voids more often come from an overactive bladder, a urinary tract infection,
thinning of the urethral lining as estrogen falls, or waking from poor sleep and then feeling the need to go. These can overlap, so glucose testing is still worthwhile when risk factors are present.

How sleep changes around perimenopause

The SWAN study followed 3,045 women aged 42–52 for 7 years (Kravitz 2008).
Trouble falling and staying asleep rose through the menopausal transition, women with more frequent hot flashes slept worse, and falling estradiol was linked with night waking.
Many women therefore wake first and then notice the urge to urinate, rather than being woken by the bladder.

Thinning of the vaginal and urethral lining

As estrogen falls, the lining of the vagina, urethra, and bladder thins, causing urgency, burning, or repeated infections, together called the genitourinary syndrome of menopause (GSM).
The NAMS 2022 position statement (NAMS 2022)
recommends low-dose vaginal estrogen when over-the-counter lubricants are not enough, and a Cochrane review of 30 trials with 6,235 women
(Lethaby 2016) found that different vaginal preparations relieve symptoms to a similar degree.

2. Blurry vision plus frequent urination: should you be tested for diabetes?

Direct answer: yes, even though small voids point elsewhere. The ADA recommends that all adults begin screening at age 35,
and blurry vision with frequent urination is a reason to check glucose before calling it an age-related symptom.

Why high glucose causes large urine volumes

The kidneys, not the pancreas, excrete excess glucose into the urine. When blood glucose rises above about 180 mg/dL, the kidneys cannot reabsorb all of it.
The glucose that escapes pulls water with it, so each void is large, thirst increases, and weight may fall. That pattern is different from passing only a little urine each time.

Who should be tested, and which cut-offs apply

ADA 2025 (ADA 2025)
defines diabetes as HbA1c of 6.5% or higher, fasting glucose of 126 mg/dL or higher, or a random glucose of 200 mg/dL or higher with symptoms.
Prediabetes is HbA1c 5.7–6.4% or fasting glucose 100–125 mg/dL. The USPSTF
(USPSTF 2021)
recommends screening adults aged 35–70 with overweight and notes that about 13% of US adults have diabetes and 34.5% meet criteria for prediabetes.

What to test in one visit

A sensible set for these symptoms is HbA1c or fasting glucose, kidney function (creatinine and eGFR), a urine test for glucose, white cells, and blood,
and liver tests if you take painkillers, herbal remedies, or drink alcohol regularly. A thyroid test (TSH) is useful when symptoms fit, such as palpitations, weight change, or unusual heat intolerance.
FSH testing is not needed to diagnose perimenopause in women aged 45 and over who have typical symptoms, according to
NICE NG23

3. Blurry vision after 40: presbyopia, high glucose, or eye disease

Direct answer: presbyopia is a common cause of blurred near vision after 40, but if distance vision is also blurry, your prescription keeps shifting over a few weeks,
or you also have heavy urination and thirst, check your glucose and see an ophthalmologist.

Presbyopia

A meta-analysis in Ophthalmology (Fricke 2018)
estimated that in 2015 about 1.8 billion people had presbyopia and 826 million had impaired near vision because they lacked suitable glasses.
The lens stiffens with age and focuses less well up close: you hold your phone farther away, struggle with small print in dim light, and your eyes tire by evening.

High glucose shifts your prescription temporarily

A study in the British Journal of Ophthalmology (Okamoto 2000)
found that when very high glucose was lowered quickly, every patient developed a temporary hyperopic shift, peaking at a mean of 1.47 diopters, and vision returned to baseline within 14–84 days.
The authors attributed it to a change in the lens refractive index rather than in corneal shape, so it is wise not to buy new glasses while glucose is still unstable.

When to have an eye exam

Get a refraction check when near vision blurs, and a dilated retinal exam once diabetes is diagnosed. Dry eye is also common at this age and causes blur that comes and goes and improves with blinking.
If vision disappears suddenly, a curtain appears, or the eye is very painful, go to the emergency department as listed in the red flags above.

4. Body aches and knee pain around perimenopause

Direct answer: muscle and joint pain become more common during the transition, but there is not enough evidence that falling estrogen alone causes knee osteoarthritis.
Thigh-strengthening exercise is the core treatment for knee osteoarthritis pain and relieves pain more clearly than paracetamol.

How common is it?

A meta-analysis of 16 studies (Lu 2020)
found muscle or joint pain in 71% of perimenopausal women, with 1.63 times the odds seen before the transition.
A larger analysis of 37 studies and 93,021 women (Kruse 2026)
found 40% before menopause, 57% during perimenopause, and 59% after menopause, a 1.35-fold increase.

Bar length = share of women with muscle or joint pain, from the Kruse 2026 meta-analysis

How much is hormonal?

These data come from observational studies, and the authors note that specific causes of pain were under-reported and heterogeneity was high.
Knee pain at this age should prompt thinking about osteoarthritis, body weight, weak thigh muscles, and other conditions, rather than blaming hormones alone.

Exercise for the knee

A Cochrane review of 44 trials with 3,537 participants (Fransen 2015)
found high-quality evidence that land-based exercise reduces knee osteoarthritis pain (SMD −0.49) and improves function. Start with seated thigh tightening, straight-leg raises, sit-to-stand from a chair,
and walking or stationary cycling, three times a week. If you carry extra weight, weight loss reduces the load on the knee.

5. Taking painkillers again and again: liver, kidneys, and stomach

Direct answer: paracetamol helps knee osteoarthritis pain only slightly and harms the liver when overdosed or doubled up. Long-term oral NSAIDs raise the risk of chronic kidney disease.
Topical NSAIDs are an option with much less drug reaching the bloodstream.

Paracetamol: small benefit for knees, and a liver caution

A BMJ meta-analysis (Machado 2015)
found that paracetamol lowered hip and knee osteoarthritis pain by only 3.7 points out of 100, below a change patients notice, and users were 3.8 times more likely to have abnormal liver tests.
A toxicology review (Chiew 2021)
describes paracetamol as the commonest cause of severe acute liver injury in Western countries, including repeated unintentional overdoses. Stay within the label dose,
do not combine painkillers or cold remedies that also contain paracetamol, and take extra care with alcohol.

Long-term oral NSAIDs and the kidneys

A meta-analysis of 40 studies with 1,757,118 participants (Soliman 2025)
linked chronic NSAID use with the onset and progression of chronic kidney disease (OR 1.24, HR 1.50), with HR 1.67 in people who already had kidney disease.
NSAIDs also raise blood pressure and stomach bleeding risk, so people with diabetes, hypertension, older age, or diuretic use need extra caution.
The classic “analgesic nephropathy” of the past was tied to combination products no longer used; today’s main risk is long-term or high-dose NSAIDs.

Topical NSAIDs for knee pain

A Cochrane review of 39 studies with 10,631 participants (Derry 2016)
found topical diclofenac and ketoprofen better than placebo for osteoarthritis pain in 6–12 week studies. Little drug reaches the blood, making them a first option before tablets for a shallow joint like the knee.

When to have your painkillers reviewed

If you need painkillers more than 2–3 days a week for over 3 months, or keep raising the dose yourself, write down the drug, dose, and number of days and show a doctor or pharmacist.
Include every herbal remedy and women’s tonic, because some contain painkillers or steroids that are not on the label.

6. Women’s tonics, herbal pills, and herbal liquors sold for aches

Direct answer: some herbal products have been found to contain hidden steroids, which relieve pain quickly but raise glucose and blood pressure, thin the bones, and suppress the adrenal glands.
Herbal liquors add alcohol, which burdens the liver when combined with paracetamol.

Data from a toxicology laboratory

A Hong Kong toxicology laboratory (Ching 2018)
reviewed 404 patients who used proprietary Chinese medicines or health products containing undeclared drugs and found 1,234 adulterants. Common groups were NSAIDs 17.7%,
steroids 13.8%, and glucose-lowering drugs 10.0%. Some 65.1% of patients had adverse effects, including drug-induced Cushing syndrome and low blood glucose.

When steroids are hidden in herbal products

A series of 61 patients who took proprietary Chinese medicines containing steroids (Chong 2015)
found dexamethasone most often, sometimes with NSAIDs as well. 11.5% needed intensive care, and 77.3% of those tested had adrenal insufficiency.
In Thailand, researchers have developed field tests for dexamethasone and prednisolone in traditional medicines (Primpray 2019)
because the problem occurs in communities.

Why people feel better so quickly

Steroids reduce inflammation and pain within days, so the product seems to work. But steroids raise blood glucose, which can increase urination and make vision fluctuate.
They also raise blood pressure, thin the bones, weaken the thigh muscles, and with longer use the adrenal glands stop making their own hormone.

Herbal liquors and alcohol

Herbs steeped in liquor add to daily alcohol intake. Alcohol increases urine output, makes sleep lighter with more night waking, and adds liver toxicity when combined with paracetamol.

Check a product before taking it

Look for a drug registration number and verify it with the national food and drug authority database. Be wary of products that promise pain relief within a day, lack a local-language label, or are sold online without a named manufacturer.
A registration number does not prove a product is free of adulteration. If your face becomes rounder, you swell, bruise easily, or your glucose rises after taking one, take the product to a doctor.

7. A 4-week plan: urination, sleep, knees, and medicines

Direct answer: start with a diary and blood tests, then add bladder training, cognitive behavioral therapy for insomnia (CBT-I), and thigh exercise,
and have a doctor review every medicine and product you take.

Week 1: diary and tests

Record voiding times and volumes for 3 days, note when and why you wake, list every painkiller and product you take, and book HbA1c, kidney function, a urine test, and a vision check.

Weeks 2–4: bladder training

A Cochrane review of 15 trials with 2,007 participants, mostly women (Funada 2023),
describes bladder training as a widely used first-line treatment for overactive bladder, although the certainty of evidence is low.
When the urge comes, stand still, squeeze the pelvic floor briefly 3–5 times until the urge fades, then walk to the toilet. Gradually lengthen the gaps between daytime voids,
cut caffeinated drinks after noon, and reduce fluids 2–3 hours before bed while still drinking enough earlier in the day.

Sleep: CBT-I before sleeping pills

In the MsFLASH randomized trial of women aged 40–65 with hot flashes (McCurry 2016),
six telephone CBT-I sessions lowered insomnia scores by 9.9 points versus 4.7 with education, and 70% of the CBT-I group no longer met insomnia criteria at 8 weeks.
Key steps: if you wake at 2 a.m. and cannot sleep for more than 20 minutes, get up for a quiet activity in dim light and return to bed when sleepy, wake at the same time every day, and avoid long daytime naps.

Knees: exercise before adding medicines

Do thigh-strengthening exercise three times a week, use a topical NSAID when it hurts, and keep oral painkillers short-term on a doctor’s or pharmacist’s advice.
If the knee becomes hot, red, and swollen or locks, see a doctor before continuing exercise.

Hormone therapy and vaginal estrogen

The NAMS 2022 position statement (NAMS 2022)
states that hormone therapy is an effective treatment for hot flashes and genitourinary symptoms, and that benefits outweigh risks for women under 60 or within 10 years of menopause without contraindications.
If hot flashes wake you every night, or urgency and burning keep returning, ask a gynecologist which hormone option fits you.
For hormone therapy versus herbal products, read
Age 46 with missed periods: hormone therapy vs herbal products

Table: what can cause night-time urination, blurry vision, and joint pain

Several causes can overlap. This table helps you prepare questions for your doctor; it is not for self-diagnosis.

Table: tests to discuss with your doctor

Your doctor chooses tests based on symptoms and history; reference ranges may differ slightly between laboratories.

Table: comparing options for knee pain, sleep, and night-time urination

Drug classes and generic names only. Choices depend on your doctor, pharmacist, other conditions, and kidney and liver function.

Common beliefs vs the evidence

The pancreas flushes excess sugar into the urine

No. The kidneys, not the pancreas, excrete excess glucose into the urine. The pancreas makes insulin, which moves glucose into cells.

Frequent night-time urination means diabetes

Not always. Diabetes with high blood glucose usually produces large volumes each time. Small voids point more toward the bladder or sleep, but glucose testing is still advised from age 35.

You need an FSH test to know you are in perimenopause

FSH testing is not needed to diagnose perimenopause in women aged 45 and over with typical symptoms, because levels swing widely at this stage.

Blurry vision just means new glasses

Presbyopia is a common cause of blurred near vision after 40, but if glucose is unstable your prescription shifts temporarily. Check glucose and see an ophthalmologist first.

Knee pain at this age is all about falling estrogen

There is not enough evidence that falling estrogen alone causes knee osteoarthritis. Thigh-strengthening exercise is the core treatment for knee osteoarthritis pain.

Herbal remedies are natural, so they have no side effects

Some herbal products have been found to contain hidden steroids, as well as NSAIDs and glucose-lowering drugs. Reported harms include Cushing syndrome, low blood glucose, and adrenal insufficiency.

All painkillers damage the kidneys equally

The clear kidney risk is long-term or high-dose oral NSAIDs. Paracetamol at normal doses mainly carries a liver risk when overdosed or doubled up.

Frequently Asked Questions (FAQ)

I wake at 2–3 a.m. to urinate often but pass only a little. Is it diabetes?

Not necessarily. Diabetes with high glucose usually causes large volumes and thirst, while small voids more often come from an overactive bladder, infection, a thinner lining as estrogen falls, or waking from poor sleep. At 46, an HbA1c test is worthwhile anyway.

What can cause blurry vision at 46?

The common cause is presbyopia, which affects about 1.8 billion people worldwide, followed by dry eye. High glucose can make your prescription fluctuate. If distance vision is also blurry or you have heavy urination and thirst, check glucose and see an eye specialist. Sudden vision loss needs the emergency department.

Which blood tests should I ask about?

HbA1c or fasting glucose, kidney function with creatinine and eGFR, a urine test, and liver tests if you take painkillers, herbal remedies, or drink alcohol regularly. Diabetes is HbA1c of 6.5% or higher or fasting glucose of 126 mg/dL or higher.

Do I need FSH and estradiol tests?

For women aged 45 and over with typical symptoms, FSH testing is not needed to diagnose perimenopause because levels fluctuate widely. Doctors rely mainly on menstrual history and symptoms.

Is knee pain around perimenopause hormonal?

Muscle and joint pain become more common during the transition. An analysis of 93,021 women found 57% in perimenopause versus 40% before, but there is not enough evidence that hormones are the only cause. Thigh exercise is the core treatment.

Will taking painkillers often damage my kidneys?

It depends on the drug. Long-term oral NSAIDs are linked with chronic kidney disease (HR 1.50), higher in people with existing kidney disease. Paracetamol mainly risks the liver when overdosed. If you need painkillers more than 2–3 days a week for months, ask a doctor to review them.

How can herbal women’s tonics or herbal pain remedies be harmful?

Some have been found to contain steroids, NSAIDs, or glucose-lowering drugs not listed on the label, which can raise glucose and blood pressure, thin bones, and suppress the adrenal glands. If you have taken one for a long time, show it to a doctor or pharmacist before stopping.

I wake at night and cannot get back to sleep. Is there a drug-free approach?

CBT-I has been studied in women of this age. A randomized trial found insomnia scores fell by 9.9 points versus 4.7. Key steps are leaving bed if you cannot sleep for more than 20 minutes, waking at the same time daily, and cutting caffeine after noon.

Scientific mechanism

Glucose in the urine: the kidneys filter glucose and reabsorb almost all of it through glucose transporters in the tubules. Above about 180 mg/dL these transporters are saturated;
the remaining glucose raises osmotic pressure in the tubule and draws water with it, producing large urine volumes. Small voids instead reflect bladder capacity or sensitivity
(ADA 2025,
Cornu 2012)

Vision that shifts with glucose: the lens exchanges glucose and water with the fluid inside the eye. When glucose changes quickly, the lens refractive index changes too, temporarily altering the prescription without changing corneal shape
(Okamoto 2000)

NSAIDs and the kidneys: NSAIDs block cyclooxygenase and reduce the prostaglandins that widen blood vessels supplying the kidney. In people whose kidneys rely heavily on prostaglandins, such as older adults, people with diabetes, dehydration, or diuretic use,
kidney blood flow falls, which is why repeated long-term use is linked with chronic kidney disease
(Soliman 2025)

Hidden steroids and the adrenal glands: external steroids feed back to suppress the hypothalamus and pituitary, so the adrenal glands stop making cortisol.
If the product is stopped abruptly, the body lacks cortisol, causing weakness, faintness, and low blood pressure
(Chong 2015)

Estrogen, the bladder, and sleep: the urethral and vaginal linings carry estrogen receptors. As estrogen falls, the lining thins and becomes more easily irritated, alongside hot flashes that cause night waking
(NAMS 2022,
Kravitz 2008)

Compiled and reviewed by Asst. Prof. Dr. Norawit Raatpiboon

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