Estrogen therapy and urinary incontinence: what is the evidence and what do we tell our patients?

Abstract

Loss of estrogen associated with menopause has been considered as a factor responsible for the increasing urinary incontinence prevalence in women as they age. Indeed, incontinence is commonly categorized as a symptom of urogenital atrophy. The presence of alpha and beta estrogen receptors throughout the urogenital tract suggests that estrogen has a role in the continence mechanism, and many observational studies have supported positive physiological effects. Estrogen has been shown to increase urethral closure pressure [1-3], increase urethral blood flow [4], increase alpha-adrenergic receptor sensitivity [5,6], and improve cellular maturation in both the urethra and vagina [7]. Based on these observational studies and a few clinical trials [8], medical management of urinary incontinence in postmenopausal women has included the use of both systemic and vaginal estrogen.A 2003 Cochrane review identified 38 clinical trials evaluating the effectiveness of estrogen for the treatment of incontinence [8]. Twenty eight randomized or quasirandomized trials were reviewed, with the authors concluding that estrogen can improve or cure incontinence. However, the randomized, double-blinded, placebo-controlled trials with adequate allocation concealment have examined the effects of estrogen or estrogen and progestin on urinary incontinence and suggest that estrogen should not be used in the prevention or relief of stress and urge incontinence. In these studies, treatment with estrogen was no better than placebo. Indeed, the longest [9] and largest [10] of these trials demonstrated a statistically significant increased risk of developing incontinence or a worsening of incontinence after the initiation of estrogen.Both the Heart Estrogen and progestin Replacement Study (HERS) and the Women's Health Initiative (WHI) were large randomized, double-blinded placebo-controlled trials evaluating the effects of estrogen for the prevention of heart disease. Both trials have now published secondary analyses assessing the effects of estrogen on self-reported urinary incontinence symptoms. The participants in HERS were randomly assigned to standard doses of oral conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) or placebo daily and followed for 4 years. In the 1,525 women who reported incontinence at baseline, CEE-MPA, the odds ratio for worsening incontinence was 1.5 among women with incontinence. In a follow-up study of women in HERS who were continent at baseline, the odds ratio for developing new stress incontinence was 1.7 and urge incontinence was 1.5 [11]. Results from the large WHI study were similar. After 1 year, standard doses of CEE with and without MPA increased the incidence of symptoms of stress and urge incontinence. The risk was greatest for stress incontinence (odds ratio for CEE-MPA was 1.8 and for CEE alone was 2.2). CEE-MPA had no significant effect on the development of urge incontinence but CEE alone increased the odds of new urge incontinence by 1.3. Women who reported incontinence at the commen...

Erkrankungen der Urogenitalorgane

“…Die orale The rapie mit Östrogenen und Gestagenen führte zu einer signifikanten Ver schlechterung der Inkontinenz (Urge und Stressinkontinenz) [12]. In den WHIStudien wurden 23 [1,14,19,20,21,29]. Der negative Ef fekt einer oralen HT erscheint biologisch nicht erklärbar."…”

“…Der negative Ef fekt einer oralen HT erscheint biologisch nicht erklärbar." [7] Diese Analyse veranlasste die Leitlini engruppe zu folgenden Statements [7]: [29] und es eine hohe Übereinstimmung zwi schen objektiver Diagnose und subjek tiven Angaben gibt [28]. Die weiteren in .…”

“…Die Atrophie der Vagina und der sie umgebenden Gewebe sowie Symptome wie Trockenheit, Jucken und Dyspare unie, die in der Postmenopause auftreten, legten die Vermutung nahe, dass ein Ös trogenmangel die Ursache der postme nopausalen urogenitalen Atrophie und der in dieser Lebensphase zunehmenden Harninkontinenz ist [15,29].…”

“…In einigen Beobachtungsstudien konn te gezeigt werden, dass Östrogene den Urethraverschlussdruck sowie die ureth rale Durchblutung steigern, die Blasen kontraktilität erhöhen und die Ausdiffe renzierung der Urethra und Vaginalzel len verbessern [29]. Basierend auf diesen Beobachtungen und wenigen klinischen Studien wurde die systemische und vagi nale Östrogenapplikation nicht nur zur Behandlung der vulvovaginalen Atrophie eingesetzt, sondern auch in das Konzept der Behandlung der weiblichen Harnin kontinenz aufgenommen.…”

Prevalência de diagnóstico médico auto-relatado de miomas uterinos em população brasileira: Padrões demográficos e socioeconômicos no Estudo Pró-Saúde *

“…Although rarely associated with malignization or mortality 2,7 , UL can have a significant impact on the quality of life of women of reproductive age 8 . Depending on their anatomical position, number and size, these tumors can cause excessive uterine bleeding and/or a prolonged menstrual period [9][10][11] ; feeling of pelvic pressure, increase in abdominal volume 10,12,13 ; pain during sexual intercourse 14 and urinary incontinence 15,16 . Additionally, the UL can have a negative impact on the reproductive function and it is associated with infertility and adverse gestational outcomes, such as spontaneous abortions, fetal anomalies, premature births, and a higher number of indications for Cesarean sections 10,[17][18][19][20][21][22] .…”