Overactive bladder syndrome treatment with ospemifene in menopausal patients with vulvovaginal atrophy: improvement of sexuality?

The effects of various therapies on vulvovaginal atrophy and quality of life in gynecological cancer patients: a systematic review

PURPOSE

Tumors affecting the female genital tract and their treatments have the potential to induce adverse modifications in vaginal health and impact personal aspects of patient's lives. Vulvovaginal atrophy is one of the morphological changes observed in individuals with a history of gynecological cancer, influenced both by the biological environment of tumors and the main therapeutic modalities employed. Therefore, the purpose of this study was to identify approaches to treat vulvovaginal atrophy while assessing the impact on the emotional and sexual health of women diagnosed with gynecological cancers.

METHODS

To achieve this goal, a systematic review was conducted following the methodological guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The databases used for literature research were PubMed and Web of Science.

RESULTS

Initially, 886 articles were obtained. After eliminating duplicates and applying inclusion/exclusion criteria, seven articles were selected for analysis. The period of highest publication activity spanned from 2017 to 2020, with the majority conducted in Italy. Five treatment modalities were identified and categorized as vaginal suppository, oral medication, surgical procedure, CO2 laser therapy, and vaginal dilator. Twenty-four outcomes related to vaginal health and 30 outcomes related to overall, sexual, and emotional quality of life were analyzed.

CONCLUSION

In general, all interventions demonstrated the ability to improve vaginal health or, at the very least, the sexual health of patients. Thus, despite limitations, all treatments have the potential to address vulvovaginal atrophy in patients with a history of gynecological cancer.

Nonestrogen Therapies for Treatment of Genitourinary Syndrome of Menopause: A Systematic Review

OBJECTIVE

To systematically review the literature and provide clinical practice guidelines regarding various nonestrogen therapies for treatment of genitourinary syndrome of menopause (GSM).

DATA SOURCES

MEDLINE, EMBASE, ClinicalTrials.gov , and Cochrane databases were searched from inception to July 2021. We included comparative and noncomparative studies. Interventions and comparators were limited to seven products that are commercially available and currently in use (vaginal dehydroepiandrosterone [DHEA], ospemifene, laser or energy-based therapies, polycarbophil-based vaginal moisturizer, Tibolone, vaginal hyaluronic acid, testosterone). Topical estrogen, placebo, other nonestrogen products, as well as no treatment were considered as comparators.

METHODS OF STUDY SELECTION

We double-screened 9,131 abstracts and identified 136 studies that met our criteria. Studies were assessed for quality and strength of evidence by the systematic review group.

TABULATION, INTEGRATION, AND RESULTS

Information regarding the participants, details on the intervention and comparator and outcomes were extracted from the eligible studies. Alternative therapies were similar or superior to estrogen or placebo with minimal increase in adverse events. Dose response was noted with vaginal DHEA and testosterone. Vaginal DHEA, ospemifene, erbium and fractional carbon dioxide (CO 2 ) laser, polycarbophil-based vaginal moisturizer, tibolone, hyaluronic acid, and testosterone all improved subjective and objective signs of atrophy. Vaginal DHEA, ospemifene, tibolone, fractional CO 2 laser, polycarbophil-based vaginal moisturizer, and testosterone improved sexual function.

CONCLUSION

Most nonestrogen therapies are effective treatments for the various symptoms of GSM. There are insufficient data to compare nonestrogen options to each other.

Urologic view in the management of genitourinary syndrome of menopause

Genitourinary syndrome of menopause (GSM) has a variety of effects on the urinary system and is an important consideration in the care provided to perimenopausal and postmenopausal patients when addressing urinary pathology. Here we discuss the common pathologies of the urinary system related to GSM including lower urinary tract symptoms and recurrent urinary tract infections. Female sexual dysfunction is not to be excluded as a critical part of a urologist's management of GSM but will be discussed elsewhere in this issue.

Update on Overactive Bladder Therapeutic Options

BACKGROUND

Millions of Americans are burdened by overactive bladder (OAB) syndrome and the psychogenic and economic hardships that accompany it. Several theories attempt to explain OAB as a neurogenic dysfunction, myogenic dysfunction, urothelial dysfunction, or decreased expression of a channel protein secondary to bladder outlet obstruction. Given that the etiology of OAB is a working theory, the management of OAB is also an evolving subject matter in medicine. There are uncertainties surrounding the pathophysiology of OAB, the strength of a clinical diagnosis, and accurate reporting because of the disease's stigma and decreased use of health care.

DATA SOURCES

This is a narrative review that used PubMed, Google Scholar, Medline, and ScienceDirect to review literature on current and future OAB therapies.

RESULTS

Currently, first-line treatment for OAB is behavioral therapy that uses lifestyle modifications, bladder-control techniques, and psychotherapy. Second-line therapy includes antimuscarinic agents or beta 3 adrenergic agonists, and studies have shown that combination therapy with antimuscarinics and beta 3 adrenergic agonists provides even greater efficacy than monotherapy. Third-line therapies discussed include onabotulinumtoxinA, posterior tibial nerve stimulation, and sacral neuromodulation. OnabotulinumtoxinA has been FDA-approved as a nonpharmaceutical treatment option for refractory OAB with minimal side effects restricted to the urinary tract. Posterior tibial nerve modulation and sacral neuromodulation are successful in treating refractory OAB, but the costs and complication rates make them high-risk procedures. Therefore, surgical intervention should be a last resort. Estrogen therapy is effective in alleviating urinary incontinence in postmenopausal women, consistent with the association between estrogen deficiency and genitourinary syndrome. Potassium channel activators, voltage-gated calcium channel blockers, and phosphodiesterase inhibitors look to be promising options for the future of OAB management. As new therapies are developed, individuals with OAB can better personalize their treatment to maximize their quality of life and cost-effective care.

Effects of ospemifene on overactive bladder in postmenopausal women with vulvovaginal atrophy

OBJECTIVE

Overactive bladder (OAB) is a complex and multifactorial syndrome associated with urinary frequency, urgency and incontinence. The menopause-associated hormonal changes play a role in the development of this condition. Vaginal estrogens are effective in improving OAB in postmenopausal women (PMW) with vulvovaginal atrophy (VVA). Ospemifene is a selective estrogen receptor modulator licensed for the treatment of VVA. This study aimed to evaluate the effects of ospemifene on OAB symptoms in PMW with VVA.

METHODS

Forty PMW suffering from OAB and VVA received oral ospemifene (60 mg/day) for 12 weeks. All patients were assessed with a urodynamic study, a 3-day bladder diary and validated questionnaires (International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form [ICIQ-UI SF] and International Consultation on Incontinence Questionnaire - Overactive Bladder [ICIQ-OAB]) at enrollment and at the end of the study.

RESULTS

Cytometric capacity, bladder compliance and verbal sensory threshold responses during bladder filling were improved after treatment. The voiding diary showed a significant reduction of daily voids, urge urinary incontinence episodes and nocturnal events. The median overall scores of the ICIQ-UI and ICIQ-OAB were also significantly improved.

CONCLUSIONS

Our study suggest that treatment with ospemifene in PMW suffering from OAB is associated with a reduction of OAB symptoms due to a decreased bladder sensitivity and with an improvement in quality of life.

TOT in combination with solifenacin or intravaginal prasterone in postmenopausal women with mixed urinary incontinence: A retrospective analysis in 112 patients

OBJECTIVES

The aim of this study was to compare the efficacy of the transobturator tape (TOT) procedure combined with solifenacin (TOT-S) or prasterone (TOT-P) in postmenopausal women affected by mixed urinary incontinence (MUI) with a predominant stress urinary incontinence component.

METHODS

This is a retrospective analysis including 112 patients: 60 patients of the TOT-S group and 52 patients of the TOT-P group. Physical examination, 3-day voiding diary, urodynamic tests, and Vaginal Health Index (VHI) were compared at the beginning of the analysis and after 12 weeks of follow-up (FU). Specific questionnaires were administered to indagate the impact on women's quality of life and sexual function.

RESULTS

After 12 weeks of FU, the detrusor's peak flow pressure was significantly different between the two groups (p = .02). Detrusor overactivity decreased only in the TOT-P group (p = .05). At the end of FU, 58 patients (96.7%) of the TOT-S group and 50 patients (96.2%) of the TOT-P group were dry at the stress test. A significative group difference was observed in urge urinary incontinence (24 h) (p = .01) but not in the mean number of voids (24 h) and urgent micturition events (24 h). VHI improved only in the TOT-P group (12.57 ± 3.80 vs. 19.75 ± 4.13, p < .0001). The questionnaires and Patient Global Index of Improvement (PGI-I) scores showed comparable improvements, while the Female Sexual Function Index improved especially in the TOT-P group (p < .001).

CONCLUSIONS

In postmenopausal women with MUI, TOT-P demonstrated the same effectiveness as TOT-S in reducing urinary symptoms. In addition, TOT-P increased VHI and sexual function scores compared with TOT-S.

Genitourinary Syndrome of Menopause

Introduced in 2014, genitourinary syndrome of menopause (GSM) describes a variety of unpleasant genital, sexual and urinary symptoms that can either be isolated or coexisting and are not related to other medical conditions. GSM is a chronic and progressive condition that requires early recognition and appropriate management to preserve urogenital health. Despite the importance of early detection and treatment, the condition is consistently underdiagnosed and undertreated. Herein, we emphasize how to diagnose GSM in postmenopausal, hypoestrogenic, and hypoandrogenic women and summarize evidence-based treatments focusing on prescription treatments and adjunctive therapies.

Current challenges in the pharmacological management of genitourinary syndrome of menopause

INTRODUCTION

Genitourinary syndrome of menopause is caused by climacteric estrogens drop and leads to bothersome and progressive genital and urinary symptoms. Considering the high frequency in the population and the impact on quality of life, it is crucial to find a safe and effective treatment. Pharmacological therapies aim to modulate the hormonal system and reverse tissue changes due to hypoestrogenism and consequently the symptoms.

AREAS COVERED

We analyzed the scientific evidence concerning the main pharmacological treatments, which include systemic and topical estrogens, prasterone and ospemifene. This literature review focused on recent safety and efficacy findings in an attempt to identify the best treatment choice for each individual patient.

EXPERT OPINION

There are encouraging data regarding the efficacy of all currently available pharmacological options and concerning their short and long-term safety. There are still doubts regarding best treatment choice for oncological high-risk population, in particular for breast cancer survivors, and some issues relative to patients' poor compliance and treatment adherence. For these reasons further studies need to be conducted with a patient-tailored focus.

[Genitourinary menopause syndrome. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

INTRODUCTION

Genitourinary menopause syndrome (SGUM) is defined as a set of symptoms associated with a decrease of estrogen and other sexual steroids during menopause. The main symptoms are vulvovaginal (dryness, burning, itching), sexual (dyspareunia), and urinary (urinary infections, pollakiuria, nycturia, pain, urinary incontinence by urgenturia). SGUM leads to an alteration of the quality of life, and affects especially women's sexuality.

OBJECTIVE

The objective of this review was to elaborate guidelines for clinical practice regarding the management of SGUM in postmenopausal women, and in particular, in women with a history of breast cancer, treated or not with hormone therapy.

MATERIALS AND METHODS

A systematic review of the literature on SGUM management was conducted on Pubmed, Medline and Cochrane Library. Recommendations from international scholarly societies were also taken into account: International Menopause Society (IMS) https://www.imsociety.org, The North American Menopause Society (NAMS) https://www.menopause.org, Canadian Menopause Society https://www.sigmamenopause.com, European Menopause and Andropause Society (EMAS) https://www.emas-online.org, International Society for the Study of Women's Sexual Health (ISSWSH) https://www.isswsh.org.

RESULTS

Vaginal use of lubricants, moisturizers and hyaluronic acid improves the symptoms of SGUM and may be offered to all patients. For postmenopausal women, local estrogen will be preferred to the oral route because of their safety and efficacy on all symptoms of SGUM during low-dose use. Prasterone is a local treatment that can be proposed as an effective alternative for the management of dyspareunia and sexual function disorder. Current data on oral testosterone, tibolone, oral or transdermal DHEA and herbal medicine are currently limited. Ospemifène, which has shown a significant improvement in sexual symptoms, is not currently marketed in France. In the particular case of women with a history of breast cancer, non-hormonal regimens are a first-line therapy. Current data on the risk of breast cancer recurrence when administering low-dose local estrogen are reassuring but do not support a conclusion that this treatment is safe.

CONCLUSION

SGUM is a common symptom that can affect the quality of life of postmenopausal women. A treatment should be systematically proposed. Local non-hormonal treatment may be offered in all women. Local low-dose estrogen therapy and Prasterone has shown an interest in the management of symptoms. In women before a history of breast cancer, local non-hormonal treatment should be offered first-line. The safety of low-dose local estrogen therapy and Prasterone cannot be established at this time. Other alternatives exist but are not currently recommended in France due to lack of data.

Non-invasive treatment of vulvovaginal atrophy in menopause with CO2 laser

Genitourinary syndrome of menopause (GSM) may affect up to 90% of menopausal women, including vulvovaginal atrophy (VVA), burning, pain, bleeding, irritation, dyspareunia, anorgasmia, and urinary symptoms. Vaginal symptoms from lack of estrogens can have a significant impact on the sexual health and quality of life (QoL) in as many as 50% of postmenopausal women. Several therapeutic alternatives, both hormonal and non- hormonal, have been proposed. Microablative CO<inf>2</inf> laser is one of the three non-surgical energy-based therapies, with Erbium:YAG laser and temperature-controlled radiofrequency (RF). Microablative CO<inf>2</inf> laser induces morphological changes in vaginal tissues and results of several clinical trials suggest that this type of laser improves symptoms of GSM. Moreover, this treatment seems to be safe. Given the increasingly widespread use of laser CO<inf>2</inf> as a non-hormonal alternative treatment for GSM, the authors reviewed the current published literature evaluating this therapy, to compare efficacy and safety of different protocols.

Update on surgical treatment of female stress urinary incontinence

INTRODUCTION

Urinary incontinence is a common condition that negatively impacts quality of life of millions of women. It is a result of a synergy between the structures of pelvic floor in particular levator ani muscle and pelvic connective tissues. Urinary incontinence, increasing with age, is associated with considerable personal and societal expenditure.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/Medline database up to August 20, 2020. Focus was only for English language publications of original studies on urinary incontinence and in particular stress urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Many surgical options exist for women with stress urinary incontinence. Nevertheless, new strategies need to be evaluated in order to improve quality of life of patients.

Urinary incontinence in women: state of the art and medical treatment

INTRODUCTION

Urinary incontinence, the involuntary loss of urine, is a common condition that affects approximately 50% of adult women. This condition increases with age, affecting 10% to 20% of all women and up to 77% of elderly women residing in nursing homes.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/MEDLINE database up to July 20, 2020. Focus was only for English language publications of original studies on urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Patients need an overview of their health condition through a detailed anamnestic collection and physical examination to identify the type of incontinence and offer the best treatment.

The Effect of Panax ginseng on Genitourinary Syndrome in Postmenopausal Women: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

BACKGROUND

Menopause and estrogen deprivation cause a rise in the number of urogenital tract complaints.

OBJECTIVE

This study was conducted to assess the effectiveness of ginseng on genitourinary syndrome.

METHODS

This randomized trial was conducted on 60 postmenopausal women with genitourinary syndrome. The participants were randomly allocated to ginseng and placebo groups twice daily for 4 weeks. Vaginal maturation index and vaginal pH were evaluated before and 4 weeks after intervention as the primary outcomes. Also, the atrophic vaginitis and incontinence questionnaires were completed before and after intervention as the secondary outcomes. The safety of intervention was assessed by the side effects checklist.

RESULTS

No significant differences were observed between the 2 groups in objective symptoms after the intervention, but the difference was statistically significant (p < 0.001) in terms of subjective symptoms of atrophic vaginitis. One case of insomnia and palpitation and 2 cases of hot flashes were reported in the intervention group, and 1 case of gastric discomfort and change in urine appearance was reported in the placebo group.

CONCLUSION

Ginseng only improved the patient-assessed symptoms and had no significant effect on the clinician-assessed outcomes. Further studies are required to determine the precise pharmacological mechanisms of ginseng on genitourinary syndrome.

Modern management of genitourinary syndrome of menopause

The genitourinary syndrome of menopause (GSM) is the accepted term used to describe the broad spectrum of genitourinary tract symptoms and signs caused by the loss of endogenous sex steroids that occurs at the time of and after the menopause. Global improvements in healthcare have resulted in an ageing population. Today, women are spending 40% of their lives in the postmenopausal state, and with 50–70% of postmenopausal women reporting symptomatic GSM, safe and efficacious treatments are needed for this troublesome condition. This article reviews current evidence for non-pharmacological and pharmacological treatments with a focus on novel and minimally invasive procedures such as energy-based devices (CO₂ laser, YAG laser), hyaluronic acid, dehydroepiandrosterone, and selective oestrogen receptor modulators.

Pharmacologic management of nocturnal polyuria: a contemporary assessment of efficacy, safety, and progress toward individualized treatment

This narrative review synthesizes current evidence on the medical management of nocturnal polyuria, including antidiuretic replacement therapy as well as other emerging modalities, with particular emphasis on areas of active investigation and future research directions. Relative to earlier formulations, the pharmacological profiles of novel desmopressin acetate nasal spray and orally disintegrating tablet formulations appear favorable in optimizing the balance between efficacy and safety. Additionally, several highly selective small-molecule arginine vasopressin 2 receptor agonists are under active development, while appropriately timed short-acting diuretics, pharmacotherapy for hypertension, nonsteroidal anti-inflammatory drugs, and sex hormone replacement therapy are also a focal point of extensive ongoing nocturnal polyuria research. Emerging laboratory technologies now make feasible a sub-stratification of nocturnal polyuria patients into substrate-based phenotypes for individualized treatment. An increasingly refined understanding of the pathogenesis of nocturnal polyuria, and arginine vasopressin dysregulation in particular, has also introduced new opportunities for point-of-care testing in patients with nocturnal polyuria.

[First-line treatment for non-neurogenic overactive bladder]

INTRODUCTION

The aim was to synthesize current knowledge on overactive bladder (OAB) first-line treatments.

METHOD

A systematic literature review based on PubMed, Embase and Google Scholar was conducted in June 2020.

RESULTS

Behavioral treatments are based on bladder training and timed voiding using a bladder diary. Lifestyle modifications should be suggested. They include reduction of fluid intake, consumption of caffeine, sodas, weight loss, avoidance of acidic fruit juices and of spicy and acidic salty diet, alkalization of urine by diet and possibly, vitamin D supplementation. Pelvic floor muscle training is mainly based on manual techniques, electrostimulation and/or biofeedback. It has been shown to be effective in treating OAB. In menopausal women, local hormone therapy improves all OAB symptoms. Oral drugs include anticholinergics and beta-3-agonists. Their efficacy is quite similar and superior to placebo. In case of failure of monotherapy, they may be combined.

CONCLUSION

Apart from some lifestyle modifications, the efficacy of first-line treatments for OAB has been demonstrated by prospective controlled studies. They may be prescribed individually or in combination.

Recent advances in managing overactive bladder

Overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence, in the absence of urinary tract infection or other obvious pathology. In this review, we focus on recent advances in the management of OAB. We examine the evidence on the effect of anticholinergic load on OAB patients. Advances in medical treatment include a new beta-3 agonist, vibegron, which is thought to have fewer drug interactions than mirabegron. Treatment of genitourinary syndrome of the menopause with oestrogens and ospemifene have also shown promise for OAB. Botulinum toxin has been shown to be an effective treatment option. We discuss the new implantable neuromodulators that are on the market as well as selective bladder denervation and laser technology.

Love in the Time of COVID-19: Sexual Function and Quality of Life Analysis During the Social Distancing Measures in a Group of Italian Reproductive-Age Women

BACKGROUND

The beginning of 2020 was characterized by the COVID-19 pandemic. The world governments have adopted restrictive measures to reduce the spread of infection. These measures could affect the sexual function and quality of life of women living with their partner.

AIM

The aim is to assess the impact of the social distancing measures caused by the COVID-19 pandemic on sexual function and quality of life of noninfected reproductive-age women, living with their sexual partner.

METHODS

Observational analysis on sexually active women, living with their partner, and without COVID-19 infection was performed. The population previously answered FSFI, FSDS, and SF-36 questionnaires. 4 weeks after the introduction of the restrictive measures, these women were invited to complete the same questionnaires by e-mail for an evaluation during the COVID-19 outbreak.

MAIN OUTCOME MEASURES

The primary endpoint was the assessment of the women's sex function change during the social restriction period, by analyzing the FSFI and FSDS questionnaires. The secondary endpoint was the evaluation of the impact on the quality of life calculated by the SF-36 questionnaire.

RESULTS

89 patients were considered. The median age was 39 (28-50) years. Mean sexual intercourses/month decreased from 6.3 ± 1.9 to 2.3 ± 1.8, mean difference: -3.9 ± 1.2. FSFI decreased significantly (29.2 ± 4.2 vs 19.2 ± 3.3, mean difference: -9.7 ± 2.6) and FSDS increased significantly (9.3 ± 5.5 vs 20.1 ± 5.2, mean difference: 10.8 ± 3.4). The SF-36 showed a significant change from 82.2 ± 10.2 to 64.2 ± 11.8 4 weeks after the introduction of the restrictive measures; mean difference: -17.8 ± 6.7. The univariable analysis identified working outside the home, university educational level, and parity ≥1 as predictive factors of lower FSFI. In multivariable analysis, working outside the home and combination of working outside the home + university educational level + parity ≥1 were the independent factors of a lower FSFI.

CLINICAL IMPLICATION

The negative impact of the COVID-19 epidemic period on sexual function and quality of life in women shows how acute stress might affect the psychological state. Thus, psychological or sexual support could be useful.

STRENGTHS AND LIMITATIONS

To our knowledge, this study is the first that analyzes the change in sexual activity in women during the COVID-19 outbreak period. The limitations were the low number of the analyzed participants, psychological tests were not included, and no data were collected on masturbation, self-heroism, solitary, and nonpenetrative sex.

CONCLUSION

The COVID-19 epidemic and the restrictive social distancing measures have negatively influenced the sexual function and quality of life in not-infected reproductive-age women who live with their sexual partners. Schiavi MC, Spina V, Zullo MA, et al. Love in the Time of COVID-19: Sexual Function and Quality of Life Analysis During the Social Distancing Measures in a Group of Italian Reproductive-Age Women. J Sex Med 2020;17:1407-1413.

Low-Intensity Extracorporeal Shock Wave Therapy Ameliorates the Overactive Bladder: A Prospective Pilot Study

Objective

In the present clinical trial, we evaluated the therapeutic effects of low-intensity extracorporeal shockwave therapy (LiESWT) on overactive bladder (OAB).

Methods

Female subjects with ages of 20-75 years and who have been clinically diagnosed with OAB were included in the study. The LiESWT (DUOLITH SD1 T-TOP, AG) applicator was placed on the suprapubic skin area and applied with an intensity of 0.25 mJ/mm², 3000 pulses, and 3 pulses/second. To assess the therapeutic efficacy, all subjects were required to complete the validated OAB symptoms and life bothersome questionnaires, 3-day urinary diary, uroflowmetry, and post-voided residual urine (PVR) measurement at 4 weeks of LiESWT (W4), 8 weeks of LiESWT (W8), 1-month follow-up (F1), and 3-month follow-up (F3) after LiESWT.

Result

82 subjects with the mean age of 56.5 ± 1.2 years were enrolled. The questionnaire scores were significantly improved at W4, W8, F1, and F3 as compared to baseline data (W0). At W8, the mean values of functional bladder capacity were meaningfully increased. According to the 3-day urinary diary, daytime frequency, urgency, and nocturia were significantly decreased. The uroflowmetry results showed that the mean voided urine volume and the maximal flow rate (Q_max) were noticeably increased. PVR volume was also significantly decreased.

Conclusions

The data demonstrated that 8-week LiESWT ameliorated the OAB symptoms, promoted the uroflow parameters, and improved the quality of life (QoL) in OAB patients, suggesting that LiESWT might serve as an alternative noninvasive therapy for OAB.

Ospemifene efficacy and safety data in women with vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a frequent, underreported and underdiagnosed condition. Ospemifene is a third-generation Selective Estrogen Receptor Modulator (SERM) that has been shown to be effective in women with VVA and dyspareunia, vaginal dryness and vulvar vestibular symptoms. Some of the possible side effects included by FDA and EMA are hot flushes, headache, muscle spasms, vaginal bleeding and vaginal discharge. Ospemifene does not increase the incidence of endometrial cancer or hyperplasia. While the efficacy is comparable with that of estrogenic treatments, ospemifene is not only well tolerated and safe but also reduces bone turnover in postmenopausal women, and available data indicate no safety concerns for breast tissue.

Experience with ospemifene in patients with vulvar and vaginal atrophy and urinary incontinence: case studies

Pelvic floor muscle atrophy and collagen loss in connective tissue due to declining estrogen production in women as they age may underlie the increasing prevalence of urge and stress incontinence. Estrogen therapy can correct the deficiency of estrogen receptors in genitourinary structures after menopause, but estrogen is not suitable for all women. A series of retrospective studies showed that urinary symptoms improved in women with overactive bladder syndrome who were receiving ospemifene for vulvovaginal atrophy (VVA), a component of genitourinary syndrome of menopause. Two case studies presented in this article support the findings. The woman in case 1 was 76 years old, had a 4-year history of urinary incontinence (UI), and several risk factors for urinary symptoms. During 15 months' treatment with ospemifene for VVA, her urinary symptoms also improved as evidenced by a reduction (from four/day to one/day) in sanitary pad requirements to manage leakage. The patient in case 2 had predominantly moderate-to-severe VVA and mild mixed UI. During 6 months' treatment with ospemifene, she experienced marked improvement in VVA symptoms, including normalization of vaginal pH and disappearance of dyspareunia, accompanied by a decrease in urinary symptoms, which allowed her to resume a normal exercise program.

Impact of Midurethral Sling Implantation on Sexual Function in Women with Stress Urinary Incontinence

Stress urinary incontinence (SUI) negatively influences sexual functions. However, the available data on sexual activity of patients who underwent midurethral sling (MUS) implantation are inconsistent. Our aim was to evaluate the impact of MUS implantation on sexual functions of women with SUI. We enrolled 171 patients undergoing the MUS procedure. Preoperative examination included the cough test, 1 h pad test and the Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA Revised (PISQ-IR). All patients had the retropubic sling implanted. Follow-up visits were performed 6-12 months after surgery. Objective cure rate was obtained in 90.98% of patients. Coital incontinence was reported by 56% of women before the surgery, and 8.6% afterwards. Among women who gained continence, significant improvement in sexual function was observed in the majority of the domains. In women who were not objectively cured (9.02%), we did not observe improvement in sexual life. All these patients indicated fear of leaking urine during sexual activity as the main cause of avoiding sex, similarly as before operation. To conclude, successful treatment of SUI with MUS significantly improves the quality of sexual life. On the other hand, persistent incontinence appears to be the most probable cause of lack of improvement in the quality of sexual life.

Potential effectiveness of Ospemifene on Detrusor Overactivity in patients with vaginal atrophy

OBJECTIVES

To report the effects on the urinary function of ospemifene prescribed for vulvovaginal atrophy (VVA) in patients with overactive bladder (OAB) symptoms refractory to the first line of pharmacologic treatment with antimuscarinic or β3-agonists drugs. We also try to identify any predictors of response to the ospemifene treatment.

STUDY DESIGN

Twenty-five patients with OAB confirmed by detrusor overactivity at urodynamics, refractory to first-line therapy for OAB, were enrolled for the study. All of them received ospemifene 60 mg for 12 weeks because of concomitant VVA. We performed a clinical examination, a 3-day voiding diary, ultrasound examination of bladder wall thickness (BWT), and evaluation by Visual Analogic Scale (VAS) of vaginal dryness at baseline and at 12 weeks. We evaluated urinary symptoms and their impact on the quality of life with UDI-6 SF and OAB-Q (Qol, sf) questionnaires.

RESULTS

After 12 weeks of treatment, we observed a significant reduction in the daily (24 h) numbers of episodes of micturition, of nocturia, of urgency and of incontinence. We also found a significant reduction in BWT and vaginal dryness, together with an improvement of OAB-Q and UDI6 SF scores. Among patients who subjectively benefited from the treatment, we found a baseline lower prevalence of constipation and a higher degree of vaginal dryness.

CONCLUSIONS

Ospemifene might be a useful option for postmenopausal women with VVA and OAB symptoms, refractory to the first line of treatment with β3-agonists or antimuscarinic drugs, before considering invasive options.

Ospemifene in the Management of Vulvar and Vaginal Atrophy: Focus on the Assessment of Patient Acceptability and Ease of Use

Endocrinological changes that occur with menopause lead to a chronic and progressive condition named vulvar and vaginal atrophy (VVA). This disease is characterized by symptoms such as dryness, dyspareunia, itching, burning, and dysuria. According to recent epidemiological studies, VVA has a high prevalence and can also occur in younger women prior to the menopause, negatively affecting quality of life, sexual function, intimacy and relationship with the partner. Accordingly, therapy should be effective, initiated early and continued for as long as possible. Up to recent years, available therapeutic options have included over-the-counter lubricants and moisturizers, vaginal oestrogens and systemic hormones. These products are not indicated for all women. Hormones are mostly contraindicated in women with a history of hormone-sensitive cancer and are frequently not accepted even by women without contraindications. Local therapies are frequently considered uncomfortable, difficult to apply, and messy. Indeed, these treatments have a high spontaneous discontinuation rate, mostly due to dissatisfaction, safety concern, side effects and difficulty in vaginal placement. Recently, ospemifene, a new non-hormonal systemic remedy, was approved by FDA (Food and Drug Administration) and EMA (European Medicines Agency) for the treatment of the two most bothersome symptoms of VVA: dryness and dyspareunia. Because ospemifene is a selective estrogen receptor modulator (SERM), it can be administered also in women with a history of breast cancer, and this makes it more acceptable by any woman. In addition, its route of administration minimizes those bothersome side effects intrinsic to the vaginal route of administration. Available data indicate that women using ospemifene have higher adherence to treatment, higher persistence and lower discontinuation rate. Satisfaction is higher than with other local therapies and overall health care cost is lower.

Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause

Introduction: Vulvovaginal atrophy (VVA), a component of the genitourinary syndrome of menopause, is a progressive condition due to decline in estrogen leading to vaginal and vulvar epithelial changes. Accompanying symptoms of dryness, irritation, burning, dysuria, and/or dyspareunia have a negative impact on quality of life. Ospemifene is a selective estrogen receptor modulator (SERM) approved by the FDA for moderate to severe dyspareunia and vaginal dryness due to postmenopausal VVA. Areas covered: PubMed was searched from inception to March 2019 with keywords ospemifene and vulvar vaginal atrophy to review preclinical and clinical data describing the safety and efficacy of ospemifene for vaginal dryness and dyspareunia due to VVA. Covered topics include efficacy of ospemifene on vaginal cell populations, vaginal pH, and most bothersome VVA symptoms; imaging studies of vulvar and vaginal tissues; effects on sexual function; and safety of ospemifene on endometrium, cardiovascular system, and breast. Expert opinion: Ospemifene is significantly more effective than placebo in all efficacy analyses studied, working through estrogen receptors and possibly androgen receptors. Safety as assessed by adverse events was generally comparable to that with placebo and to other SERMs, and/or adverse events were not clinically meaningful. No cases of endometrial or breast cancer were reported.

Effectiveness of hormones in postmenopausal pelvic floor dysfunction-International Urogynecological Association research and development-committee opinion

Introduction and hypothesis

There is clear evidence of the presence of estradiol receptors (ERs) in the female lower urinary and genital tract. Furthermore, it is a fact that estrogen deficiency after menopause may cause atrophic changes of the urogenital tract as well as various urinary symptoms. Moreover, the effect of hormone replacement therapy (HRT) on urinary incontinence (UI) symptoms as well as pelvic organ prolapse (POP), anal incontinence (AI) and vulvovaginal symptoms (VVS) is still a matter of debate. This committee opinion paper summarizes the best evidence on influence of sex steroids as well as hormonal treatment (local and systemic) in postmenopausal women with pelvic floor disorders.

Methods

A working subcommittee from the International Urogynecology Association (IUGA) Research and Development Committee was formed. A thorough literature search was conducted and an opinion statement expressed. The literature regarding hormones and pelvic floor disorders was reviewed independently and summarized by the individual members of the sub-committee.

Results

The majority of studies reported that vaginal estrogen treatment when compared with placebo has more beneficial effects on symptoms and signs of vaginal atrophy including sensation of burning, dyspareunia and UI symptoms. Definitive evidence on local estrogen application and prolapse treatment or prevention is lacking. A statistically significant increase in risk of worsening of UI as well as development of de novo incontinence was observed with estrogen-only or combination systemic HRT.

Conclusions

In summary, local estrogen seems to be safe and effective in the treatment of VVS and can also improve urinary symptoms in postmenopausal patients with UI, but most of these recommendations correspond to evidence level 2C. The evidence in POP is still scarce but not in favor of benefit. Finally, the duration of local estrogen treatment (LET), optimal dosage, long-term effects and cost-effectiveness compared with current practice are still unknown.