Menopause hormonal therapy from the urologist’s perspective

Abstract

Many of the paradigms about hormone-replacement therapy in the postmenopausal female have changed drastically recently. Estrogen was thought to be cardioprotective for women until the landmark Heart and Estrogen/progestin Replacement Study [1] and the twin Women's Health Initiative studies [2,3] confirmed that neither combination estrogen with progesterone therapy (EPT) nor estrogen therapy (ET) alone are protective of coronary events in women with established coronary vascular disease. Sex steroid supplementation for female sexual dysfunction is widely promoted, despite sparse evidence of use outside of those with hypopituitary deficiency [4] or surgically induced menopause [5]. Given the increased risk of cardiac events, stroke [6], breast [7-9], endometrial [10] and ovarian cancers [11][12][13], and the aromatization of androgens to estrogenic compounds in fatty tissues and muscle [14,15] with the use of ET and EPT, a risk-benefit assessment for sex steroid supplementation for women with genitourinary complaints appears to be limited to short-term local estrogen therapy for vulvovaginal complaints in patients with documented vaginal atrophy.Indeed, the effects of menopause on urogenital function also have been upturned. Menopause is symptomatic in variable percentages of women, with vasomotor symptoms occurring in most women, of whom 50% will continue to have symptoms for at least 5 years [16][17][18]. Estrogen-related atrophic vaginitis produces symptoms of vaginal burning, itching, and secondary dyspareunia and is responsive to estrogen supplementation in 60% of the case [19]. Using a locally applied estrogen cream is as effective as systemic use in the treatment of atrophic vaginitis [20] and is recommended [21]. Determining if vulvovaginal complaints are the result of vaginal atrophy prior to instituting estrogen therapy is accomplished by vaginal cytology, which will show the characteristic increase in basal and parabasal cells.It remains clear that gradual loss of estrogen results in lower glycogen production by the now thinning vaginal epithelium. This reduction reduces the population of glycogen-dependent lactobacilli, allowing coliform bacteria to populate the vagina. This increases the reservoir of urinary pathogens and changes the microbiology of the woman with postmenopausal urinary tract infections (UTI) in the more acidic environment that results. However, although the epidemiology of UTI changes over the life cycle, the risk of a UTI does not appear to be significantly affected by estrogen status [22][23][24][25][26]. Indeed, those women taking higher daily doses of ET were found to be at an increased risk of UTI compared with those not undergoing ET [25]. The greatest risk for a community-acquired UTI in the postmenopausal female is her lifetime history of UTI [26,27].Likewise, despite older studies to the contrary, estrogen replacement does not appear to significantly alter the recurrence rate for UTI. A double-blind, randomized, placebo-controlled trial (RPCT) of low-dose ET for recurrent U...

Comparison of the effects of oestrogen deficiency and old age on primary bladder afferent activity and voiding behaviour in the ageing female rat

“…Even if it may affect storage function in the rat, it seems unlikely that E deficiency per se is the main driver of the increase in afferent activity and voiding frequency that is observed in ageing female rats. It has also been suggested that, although the prevalence of urinary incontinence increases with age, the increase might not be related directly to E deficiency in the postmenopausal female [8]. The present study suggests that changes in afferent activity that are associated with age in the ageing female rat model may contribute to bladder overactivity independent of a decrease in E.…”

“…A population‐based survey confirms that the prevalence of LUTS increases with age [3], and separate studies have shown that although the incidence of overactive bladder (OAB) is similar in men and women, the characteristics of the disease differ with gender, with a larger proportion of women experiencing urge incontinence (OAB wet) than that of men [4,5]. However, it has not been possible to dissociate the age‐related changes from the changes in the urogenital tract that are associated with a decline in circulating E levels associated with menopause which can lead to various urogenital disorders, including those of the OAB syndrome [6], and the effects of hormone replacement on OAB symptoms in postmenopausal women are controversial [7,8].…”