The mysteries of menopause and urogynecologic health: clinical and scientific gaps

The Effect of Menopause on Vaginal Tissue Mechanics: A Brief Review

Often called "the change of life," menopause affects every part of a woman's body. As the sex hormones decrease, the reproductive organs experience the most remarkable changes, with the vagina becoming thinner, drier, and less elastic. Despite the important implications of these changes in genitourinary conditions, there are only a few experimental studies that focus on quantifying the effect of menopause on the mechanical properties of the vagina. These studies are mostly conducted using uniaxial tests on strips of vaginal tissues isolated from rats, rabbits, and sheep and, in only a few cases, from humans. The purpose of this article is to present a systematic review of experimental protocols, methods, and results that are currently published on how menopause alters the mechanical behavior of the vagina. This review will enable new investigators in the biomechanics field to identify important gaps and frame research questions that inform the design of new treatment options for menopausal symptoms.

Novel Antimicrobial Approaches to Combat Bacterial Biofilms Associated with Urinary Tract Infections

Urinary tract infections (UTIs) are prevalent bacterial infections in both community and healthcare settings. They account for approximately 40% of all bacterial infections and require around 15% of all antibiotic prescriptions. Although antibiotics have traditionally been used to treat UTIs for several decades, the significant increase in antibiotic resistance in recent years has made many previously effective treatments ineffective. Biofilm on medical equipment in healthcare settings creates a reservoir of pathogens that can easily be transmitted to patients. Urinary catheter infections are frequently observed in hospitals and are caused by microbes that form a biofilm after a catheter is inserted into the bladder. Managing infections caused by biofilms is challenging due to the emergence of antibiotic resistance. Biofilms enable pathogens to evade the host's innate immune defences, resulting in long-term persistence. The incidence of sepsis caused by UTIs that have spread to the bloodstream is increasing, and drug-resistant infections may be even more prevalent. While the availability of upcoming tests to identify the bacterial cause of infection and its resistance spectrum is critical, it alone will not solve the problem; innovative treatment approaches are also needed. This review analyses the main characteristics of biofilm formation and drug resistance in recurrent uropathogen-induced UTIs. The importance of innovative and alternative therapies for combatting biofilm-caused UTI is emphasised.

A Bird's-Eye View of the Pathophysiologic Role of the Human Urobiota in Health and Disease: Can We Modulate It?

For a long time, urine has been considered sterile in physiological conditions, thanks to the particular structure of the urinary tract and the production of uromodulin or Tamm-Horsfall protein (THP) by it. More recently, thanks to the development and use of new technologies, i.e., next-generation sequencing and expanded urine culture, the identification of a microbial community in the urine, the so-called urobiota, became possible. Major phyla detected in the urine are represented by Firmicutes, Bacteroidetes, Proteobacteria, and Actinobacteria. Particularly, the female urobiota is largely represented by Lactobacillus spp., which are very active against urinary pathogenic Escherichia (E.) coli (UPEC) strains via the generation of lactic acid and hydrogen peroxide. Gut dysbiosis accounts for recurrent urinary tract infections (UTIs), so-called gut-bladder axis syndrome with the formation of intracellular bacterial communities in the course of acute cystitis. However, other chronic urinary tract infections are caused by bacterial strains of intestinal derivation. Monomicrobial and polymicrobial infections account for the outcome of acute and chronic UTIs, even including prostatitis and chronic pelvic pain. E. coli isolates have been shown to be more invasive and resistant to antibiotics. Probiotics, fecal microbial transplantation, phage therapy, antimicrobial peptides, and immune-mediated therapies, even including vaccines for the treatment of UTIs, will be described.

Efficacy of Lactiplantibacillus plantarum PBS067, Bifidobacterium animalis subsp. lactis BL050, and Lacticaseibacillus rhamnosus LRH020 in the Amelioration of Vaginal Microbiota in Post-Menopausal Women: A Prospective Observational Clinical Trial

The menopausal transition marks a significant physiological shift in women. Menopause-related symptoms can significantly affect a woman's quality of life and probiotics have emerged as a promising avenue. This study aims to investigate the benefits of probiotics in improving vaginal well-being and microbiota composition in post-menopausal women. A prospective observational clinical trial was carried out enrolling 50 post-menopausal healthy women, aged between 45 and 65 years old, taking a supplement containing Lactiplantibacillus plantarum PBS067, Bifidobacterium animalis subsp. lactis BL050, and Lacticaseibacillus rhamnosus LRH020 (3B CFU/day) for 28 days. Vaginal swabs were collected to evaluate microbiota fluctuation and the inflammatory pattern was recorded. A Vaginal Health Index was provided to evaluate vaginal well-being throughout the trial. Clinical outcomes revealed a decrease in menopausal symptoms. Significant improvements were observed across various parameters: a 50% enhancement in the VHI score (p < 0.0001), alongside substantial reductions in inflammatory cytokine levels. An 87.8% decrease in IL-6, 57.6% in IL-1β, and 40.8% in TNF-α was observed (p < 0.05). Moreover, the probiotic intervention facilitated the restoration of vaginal microbiota, evidenced by an increase in lactobacilli abundance. In conclusion, the combination of these specific probiotic strains, previously clinically tested in childbearing-age women, showed to be effective also for post-menopausal women.

The alteration of apoptosis-related genes in female pelvic supportive tissues with regard to menopausal status

PURPOSE

We aimed to compare the expression levels of anti-apoptotic and proapoptotic genes in the parametrium, sacrouterine and round ligaments with respect to menopausal status in women presenting without any indication of pelvic organ prolapse (POP). We hypothesized that apoptosis related gene expressions in female pelvic tissues may be altered during menopause.

METHODS

The study groups consisted of pre-menopausal (n = 10) and menopausal (n = 10) females who did not have POP symptoms. Three different types of tissue samples (Parametrium, Round Ligament and Sacrouterine Ligament) were obtained and RNA was isolated from these tissues. After purifying and quantifying RNA samples, qPCR was used to determine the expression levels of anti-apoptotic and pro-apoptotic genes.

RESULTS

BCL-2 gene expression levels were significantly lower in all the tissues of menopausal patients compared to those of premenopausal patients. In comparison to premenopausal patients, the sacrouterine ligament tissue BAD expression level was significantly high (p = 0.035), and the BCL-2/BAD ratio was significantly lower in menopausal patients (p = 0.006).

CONCLUSION

Apoptosis-related protein levels change during menopause; pro-apoptotic gene expressions decrease and anti-apoptotic gene expressions increase. The significant alteration of BCL-2 and BAD expression in sacrouterine ligament with respect to menopausal status was observed and this suggested that when compared to other pelvic tissues, the sacrouterine ligament, which plays a crucial role for genital organs in restoring normal pelvic anatomy and providing support, could be affected more by menopause.

Genitourinary syndrome of menopause and intestinal microbiota

Introduction

Genitourinary syndrome of menopause (GSM) is one of the pathological symptoms of menopause, which causes significant physical, psycho-emotional, and sexual discomfort to a woman.

Material and methods

The study describes an examination of 65 middle-aged women, who were divided into 2 groups. Group I included 39 patients with GSM, who, depending on the duration of symptoms (3-5 years, more than 7 years), were divided into subgroups Ia and Ib. Group II included 26 patients who did not have clinical manifestations of GSM. All patients underwent general clinical studies. Bacteriological examination of faeces was used to assess the state of the intestinal microbiota.

Results

It was found that menopause occurred in women with GSM earlier, compared with patients without manifestations of urogenital disorders. Also, the women with GSM were more likely to be diagnosed with type 2 diabetes mellitus, metabolic syndrome, overweight, and iron deficiency anaemia. When analysing the results of a bacteriological study in this group of patients, a statistically significant decrease in the colonization of Bifidobacterium and Lactobacillus, as well as excessive bacterial growth of such conditionally pathogenic bacteria as Escherichia coli with reduced enzymatic activity, and Klebsiella and Streptococcus was revealed. Conclusions: Conducting a fundamental study on the characteristics of the intestinal microbiota in menopausal disorders will be an important step towards understanding the pathogenetic mechanisms of their formation, and correction of intestinal metabolism can become an important condition for effective prevention and treatment.

Urinary incontinence in women: assessment with the aid of standardized nursing terminologies NANDA-I and NOC

OBJECTIVES

to assess urinary impairment in incontinent women with the aid of standardized nursing terminologies NANDA-I and NOC.

METHODS

a cross-sectional study, carried out with 97 women attending the gynecology outpatient clinic of a university hospital. Data collection took place using a form that contained information about NANDA-I diagnoses related to urinary incontinence and NOC Urinary Continence indicators. Statistical analysis was performed to assess the impairment of NOC indicators in the presence of NANDA-I nursing diagnoses.

RESULTS

diagnosis Mixed Urinary Incontinence was the most prevalent (43.3%), and, in its presence, the most compromised indicators were voids in appropriate receptacle, gets to toilet between urge and passage of urine and empties bladder completely.

CONCLUSIONS

urinary impairment was worse in women with elements of stress and urge urinary incontinence.

Therapeutic Effects of Vitamin D on Vaginal, Sexual, and Urological Functions in Postmenopausal Women

Recent years have witnessed the emergence of growing evidence concerning vitamin D's potential role in women's health, specifically in postmenopausal women. This evidence also includes its connection to various genitourinary disorders and symptoms. Numerous clinical studies have observed improvements in vulvovaginal symptoms linked to the genitourinary syndrome of menopause (GSM) with vitamin D supplementation. These studies have reported positive effects on various aspects, such as vaginal pH, dryness, sexual functioning, reduced libido, and decreased urinary tract infections. Many mechanisms underlying these pharmacological effects have since been proposed. Vitamin D receptors (VDRs) have been identified as a major contributor to its effects. It is now well known that VDRs are expressed in the superficial layers of the urogenital organs. Additionally, vitamin D plays a crucial role in supporting immune function and modulating the body's defense mechanisms. However, the characterization of these effects requires more investigation. Reviewing existing evidence regarding vitamin D's impact on postmenopausal women's vaginal, sexual, and urological health is the purpose of this article. As research in this area continues, there is a potential for vitamin D to support women's urogenital and sexual health during the menopausal transition and postmenopausal periods.

Trajectories of depressive symptoms over 20 years and subsequent lower urinary tract symptoms and impact among women

OBJECTIVE

The aim of the study is to examine the association between depressive symptoms and subsequent lower urinary tract symptoms (LUTS) and impact (a composite outcome) among women (N = 1,119) from the Coronary Artery Risk Development in Young Adults study.

METHODS

The Center for Epidemiologic Studies-Depression Scale (CES-D) was administered in 1990-1991 and every 5 years through 2010-2011. In 2012-2013, LUTS and impact data were collected for the first time. Accumulation of risk was examined in the following three ways: (1) mean CES-D score across 20 years (5 observations); (2) depressive symptom trajectory group, determined by group-based trajectory modeling; and (3) intercepts and slopes obtained from women's individual CES-D score trajectories through two-stage mixed effects modeling. For each approach, ordinal logistic regression analyses examined odds of having "greater LUTS/impact" for each unit change in a depressive symptom variable.

RESULTS

(1) With each one-unit increase in mean CES-D score over the 20-year period, women were 9% more likely to report greater LUTS/impact (odds ratio [OR] = 1.09, 95% CI = 1.07-1.11). (2) In comparison with women with consistently low depressive symptoms, women with consistently threshold depression or consistently high depressive symptoms were twice (OR = 2.07, 95% CI = 1.59-2.69) and over five times (OR = 5.55, 95% CI = 3.07-10.06) as likely, respectively, to report greater LUTS/impact. (3) Women's individual symptom intercept and slope interacted. Increases in depressive symptoms across 20 years (greater slopes) were associated with greater LUTS/impact when women's initial CES-D score (intercept) was in the moderate-to-high range relative to the sample.

CONCLUSIONS

Depressive symptoms over 20 years, examined with different degrees of nuance, were consistently associated with subsequently measured LUTS and impact.

Quantification of senescence-associated secretory phenotype proteins in the vaginal secretions of pre- and postmenopausal women with and without prolapse

Objectives

Cellular senescence has been proposed as a pathophysiologic driver in the development of pelvic organ prolapse (POP), especially during aging. In this study, we aimed to determine if markers of cell senescence can be quantified from vaginal secretions collected from pre- and postmenopausal women with and without POP.

Methods

Vaginal swabs were collected from 81 women in four groups: premenopausal with (pre-P) and without prolapse (pre-NP), and postmenopausal with (post-P) and without prolapse (post-NP). Multiplex immunoassays (MagPix) were then used to detect and quantify the presence of 10 SASP proteins in vaginal secretions.

Results

The total protein concentration of vaginal secretions differed significantly among the four groups (P = 0.003) with highest mean concentrations in pre-P [16, interquartile range (IQR) = 4.6, 38.3 μg/μL] and lowest mean concentrations in post-P (4.4, IQR = 2.6, 7 μg/μL). The normalized concentrations of several SASP markers differed significantly among groups, with the highest concentrations being seen in the post-P group, and the lowest concentrations being in the pre-NP group. Using these key markers, we then constructed receiver-operator curves to determine the relative sensitivity and specificity of these markers in predicting prolapse.

Conclusions

In this study, we found that SASP proteins can be detected and quantified in vaginal secretions. Several of these markers were differentially expressed among the four groups studied, with the highest normalized concentrations of SASP markers found among postmenopausal women with prolapse. Overall, the data support the theory that senescence is associated with prolapse during aging but that other factors may be important in younger women who develop POP before menopause.

An Audit to Reevaluate the Adherence to the Guidelines in Patients With Urinary Tract Infection at the Al-Karak Hospital in Jordan

Background Urinary tract infection (UTI) is a common and costly health problem that affects millions of people worldwide. The proper management of UTI requires adherence to clinical guidelines that are based on the best available evidence. However, compliance with these guidelines in real-world practice is often suboptimal. Objective This study is aimed to audit and reevaluate the adherence to the guidelines in UTI patients at Al-Karak Hospital, Jordan. Methods A retrospective cohort study was conducted. The first loop included 50 patients who presented with symptoms of simple uncomplicated UTI and were treated at the clinic during a three-month period. The second loop included a reevaluation of the first loop's findings after implementing changes to the clinical practice based on the initial audit results. Results The main factors that influenced the adherence were the type of UTI, the presence of comorbidities, the duration of hospitalization, and the antibiotic choice. At the first loop, the audit findings identified that the 100% standard National Institute for Health and Care Excellence (NICE) guidelines met the reach of 20 (40%) of the 50 patients. A revaluation of the audit findings identified that the 100% standard NICE guidelines met the reach of 36 of the 50 (72%) patients. Conclusion The study concluded that there is a need to improve adherence to the guidelines in UTI patients at the Al-Karak Hospital and suggested some recommendations to achieve this goal.

Effectiveness of vaginal estriol with lactobacilli on urinary symptoms in postmenopausal women: a randomized-controlled trial

OBJECTIVE

The aim of this study was to compare the effects of a vaginal tablet containing estriol (0.03 mg) plus lactobacilli (E3/L) with placebo on lower urinary tract symptoms (LUTS) in postmenopausal women (PMW).

METHODS

This randomized, double-blinded, placebo-controlled trial was conducted at Srinagarind Hospital in Khon Kaen, Thailand. PMW with at least one LUTS, such as frequency, nocturia, dysuria, urgency, or stress or urgency urinary incontinence, were recruited. Participants were randomly assigned to receive either an E3/L tablet or placebo, administered vaginally daily at bedtime for 2 weeks, then twice a week for another 2 weeks. Symptom severity score was assessed using a visual analog scale (VAS), and quality of life (QOL) was measured using the validated Thai version of the Incontinence Impact Questionnaire-Short Form. The primary outcome was proportion of the PMW with LUTS improvement. Secondary outcomes were symptom severity score, participant satisfaction, QOL, and adverse events. Relative risk and 95% confidence intervals (CIs) were calculated using the chi-square or Fisher's exact test. An independent-sample and paired t test were used to compare means.

RESULTS

Thirty-eight participants in each group completed the study. The proportion of PMW whose symptoms improved (both in terms of most bothersome symptom and overall) did not differ significantly between the two groups. Relative risk was 1.00 (95% CI, 0.74-1.36) and 0.90 (95% CI, 0.71-1.15), respectively. There were no differences in symptom severity score, participant satisfaction, or QOL.

CONCLUSIONS

A 1-month course of vaginal E3/L does not appear to improve LUTS in PMW.

Genitourinary syndrome in menopause: Impact of vaginal symptoms

Objective

To describe the impact of genitourinary syndrome symptoms on daily activities and well-being in peri- and postmenopausal women living in an urban area.

Materials and Methods

Observational, prospective, and cross-sectional research in a population of peri- and postmenopausal women living in the Lima region. A non-probabilistic sample was used. The instrument used is "The Day-to-Day Impact of Vaginal Aging" questionnaire. It consists of four domains and its internal reliability is between 0.82 and 0.93. The questions were answered using a Likert scale. High values indicate a more severe impact. Statistical procedures were performed using SPSS version 26.

Results

One thousand seventy women participated; the mean age was 54±7.5 years. The results about the activities of daily living showed that 35% of women reported regular vaginal symptoms and 14.7% major symptoms. In the emotional well-being domain, 90% had minor symptoms. In the sexual function domain, 57.6% reported minor vaginal symptoms, and in the self-concept and body image domain, 60.9% reported minor symptoms and 20.7% major symptoms. According to the global score, 60.9% reported minor discomfort, 36.3% regular discomfort, and 2.8% major discomfort. The sexually active women declared an impact of severity in terms of their daily activities and sexual function (p<0.05).

Conclusion

There is a relationship between activities of daily living, sexual function, and women with sexual activity, causing a negative impact on social life and quality of life.

Urinary Incontinence in Elite Female Athletes

PURPOSE OF REVIEW

To summarize the current understanding on the epidemiology, pathophysiology, and management strategies of urinary incontinence (UI) in female athletes, highlighting findings specific to nulliparous elite athletes.

RECENT FINDINGS

UI occurs in about 20-50% of female athletes of all ages and parity status, around 40% for younger nulliparous athletes, and is more prevalent in high-impact sports. Possible contributing factors to UI in female elite athletes include pelvic floor laxity and bladder neck descent, pelvic floor muscle fatigue, low energy availability, and hypermobility syndrome. In female elite athletes, urinary symptoms negatively affect quality of life, although the effects of symptoms on exercise participation are not well understood. Current management strategies are primarily conservative and centered on behavioral modifications and pelvic floor muscle physiotherapy. UI in female elite athletes appears to be multifactorial. Clarifying how individual factors influence UI in this population will inform athlete counseling, prevention, and treatment strategies.

The Vaginal Microbiome in Health and Disease-What Role Do Common Intimate Hygiene Practices Play?

The vaginal microbiome is a dynamic, sensitive microenvironment. The hallmark of a 'healthy' vaginal microbiome is currently believed to be one dominated by Lactobacillus spp., which acidifies the vaginal environment and help to protect against invading pathogens. However, a 'normal' microbiome is often difficult, if not impossible, to characterise given that it varies in response to numerous variables, including pregnancy, the menstrual cycle, contraceptive use, diet, ethnicity, and stress. A Lactobacillus-depleted microbiome has been linked to a variety of adverse vaginal health outcomes, including preterm birth (PTB), bacterial vaginosis (BV), and increased risk of sexually transmitted infections. The latter two of these have also been associated with feminine intimate hygiene practices, many of which are practised without any evidence of health benefits. The most extensively studied practice is vaginal douching, which is known to cause vaginal dysbiosis, predisposing women to BV, pelvic inflammatory disease, and PTB. However, little is known of the impact that intimate hygiene practices and associated products have on the vaginal microbiome. This review aims to outline the major factors influencing the vaginal microbiome and common vaginal infections, as well as to summarise current research surrounding the impact of hygiene products and practices on the vaginal microbiome.

G protein-coupled estrogen receptor (GPER/GPR30) levels in pelvic floor muscles and its association with estrogen status in female rabbits

Objective: To assess the relative expression of the G-protein coupled estrogen receptor (GPER) in the bulbospongiosus (Bsm) and pubococcygeus (Pcm) muscles in control, ovariectomized (OVX), and OVX with estradiol benzoate supplementation (OVX + EB) rabbits.Methods: We used tissues from C, 1-month OVX, and OVX plus 15-day EB implanted (OVX + EB) groups. The GPER expression was evaluated by Western blot and immunohistochemistry for both Bsm and Pcm. Results: Both muscles showed a GPER immunoreactivity in blood vessels, inside myofibers next to myonuclei, and in polymorphonuclear cells. Four-week ovariectomy did not modify the GPER expression in the Bsm and Pcm, but two-week estradiol benzoate increased it in the latter muscle alone.Conclusions: We demonstrated that the Bsm and Pcm of female rabbits express GPER. High serum estradiol levels elevate GPER relative expression in the Pcm alone. The present study supports the remarkable estrogen sensitivity of the Pcm.

Biaxial Murine Vaginal Remodeling With Reproductive Aging

Higher reproductive age is associated with an increased risk of gestational diabetes, pre-eclampsia, and severe vaginal tearing during delivery. Further, menopause is associated with vaginal stiffening. However, the mechanical properties of the vagina during reproductive aging before the onset of menopause are unknown. Therefore, the first objective of this study was to quantify the biaxial mechanical properties of the nulliparous murine vagina with reproductive aging. Menopause is further associated with a decrease in elastic fiber content, which may contribute to vaginal stiffening. Hence, our second objective was to determine the effect of elastic fiber disruption on the biaxial vaginal mechanical properties. To accomplish this, vaginal samples from CD-1 mice aged 2-14 months underwent extension-inflation testing protocols (n = 64 total; n = 16/age group). Then, half of the samples were randomly allocated to undergo elastic fiber fragmentation via elastase digestion (n = 32 total; 8/age group) to evaluate the role of elastic fibers. The material stiffness increased with reproductive age in both the circumferential and axial directions within the control and elastase-treated vaginas. The vagina demonstrated anisotropic mechanical behavior, and anisotropy increased with age. In summary, vaginal remodeling with reproductive age included increased direction-dependent material stiffness, which further increased following elastic fiber disruption. Further work is needed to quantify vaginal remodeling during pregnancy and postpartum with reproductive aging to better understand how age-related vaginal remodeling may contribute to an increased risk of vaginal tearing.

Characteristics Associated With Repeated Evaluations for Urinary Tract Infections in Older Women: A Case-Control Study

OBJECTIVES

The aims of this study were to estimate the incidence of repeated evaluations for urinary tract infection (UTI) after a single occurrence and to identify characteristics associated with repeated evaluations in a female Medicare population.

METHODS

This was a case-control study of women aged 65 years or older undergoing incident outpatient evaluation for UTI between the years of 2011 and 2018. We defined UTI evaluation as an outpatient encounter with diagnostic codes for UTI and an order for urine culture. We excluded women with diagnostic codes suggestive of a complicated UTI. Among all women with an incident UTI evaluation, cases were defined as those with repeated evaluations, defined as either a total of ≥2 UTI evaluations in 6 months and/or ≥3 in 1 year. The characteristics of cases versus controls were compared with both an unadjusted and adjusted logistic regression model.

RESULTS

Our overall cohort consisted of 169,958, of which 13,779 (8.1%) had repeated evaluations for UTI. In unadjusted analyses, cases were more likely to be older than 75 years, of White race, and to have cardiovascular conditions, diabetes, dementia, renal disease, and chronic obstructive pulmonary disease (all P's < 0.01) as compared with controls. In adjusted analysis, ages 75 years to 84 years (P < 0.01) and ages older than 84 years (P < 0.01) along with multiple medical comorbidities were significant risk factors for repeated evaluations for UTI. Black women had lower odds of repeated evaluations for UTI (P < 0.01).

CONCLUSIONS

Among women with a single UTI evaluation, repeated evaluations for UTI were associated with older age, White race, and medical comorbidities. Future studies should investigate racial disparities seen in care-delivery behavior and/or care-seeking behavior.

Clinical evaluation of autologous platelet rich plasma injection in post menopausal vulvovaginal atrophy; A pilot study

BACKGROUND

There is lack of published data investigating injection of autologous platelet rich plasma (A-PRP) alone in treatment of postmenopausal VVA.

OBJECTIVES

In this pilot study, we aimed to investigate the safety and efficacy of injection of A-PRP alone in postmenopausal VVA in women without history of cancer breast to explore its utility as a hormone free therapy for postmenopausal VVA and for vulvovaginal rejuvenation.

METHODS

In this pilot study, 47 women with postmenopausal VVA were included. Vulvovaginal condition was evaluated at the baseline by vaginal health index (VHI). Impact of VVA on quality of life and sexual life was evaluated at the baseline by vulvovaginal symptom questionnaire (VSQ). Treatment protocol was 2 sessions of A-PRP injection with one month interval. Response was evaluated one month after the last session by VHI and VSQ. Side effects were also evaluated.

RESULTS

Post menopausal VVA was significantly improved by A-PRP injection as indicated by significant improvement of total VHI score and its items at 1 month post treatment ( p vlue < 0.001). Also, there was significant improvement of burning, hurting, being irritated, being dry, discharge, desire to be intimate, sexual relationships, pain during sexual activity, and dryness during sexual activity at 1 month post treatment as indicated by VSQ ( p value = 0.045 for being dry and < 0.001 for other items).

CONCLUSIONS

A-PRP injection is safe and effective as minimally invasive monotherapy for postmenopausal VVA without history of cancer breast and hence for vulvovaginal rejuvenation.

Epithelial arginase-1 is a key mediator of age-associated delayed healing in vaginal injury

Pelvic organ prolapse is a disorder that substantially affects the quality of life of millions of women worldwide. The greatest risk factors for prolapse are increased parity and older age, with the largest group requiring surgical intervention being post-menopausal women over 65. Due to ineffective healing in the elderly, prolapse recurrence rates following surgery remain high. Therefore, there is an urgent need to elucidate the cellular and molecular drivers of poor healing in pelvic floor dysfunction to allow effective management and even prevention. Recent studies have uncovered the importance of Arginase 1 for modulating effective healing in the skin. We thus employed novel in vitro and in vivo vaginal injury models to determine the specific role of Arginase 1 in age-related vaginal repair. Here we show, for the first time, that aged rat vaginal wounds have reduced Arginase 1 expression and delayed healing. Moreover, direct inhibition of Arginase 1 in human vaginal epithelial cells also led to delayed scratch-wound closure. By contrast, activation of Arginase 1 significantly accelerated healing in aged vaginal wounds in vivo, to rates comparable to those in young animals. Collectively, these findings reveal a new and important role for Arginase 1 in mediating effective vaginal repair. Targeting age-related Arginase 1 deficiency is a potential viable therapeutic strategy to promote vaginal healing and reduce recurrence rate after surgical repair of pelvic organ prolapse.

Association between myostatin serum concentration and body fat level in peri- and postmenopausal women

INTRODUCTION

Every year over 25 million women worldwide experience menopause symptoms. Menopause leads to the occurrence and intensification of many psychological and somatic disorders including body composition change. Myostatin may play a crucial role in the remodeling of muscle and fat tissue. The aim of the study was to determine the relationship between the level of body fat and the concentration of myostatin protein in serum of peri- or postmenopausal women.

MATERIAL AND METHODS

The study included 300 Caucasian women (in perimenopause or postmenopause). Detailed data were collected at a single time point from all enrolled women. The data included: age, body mass index, hormone replacement therapy and body fat. Measurements of adipose tissue were performed using electronic skinfold calipers. Serum levels of myostatin were determined using a Human Myostatin ELISA Kit.

RESULTS

The mean myostatin concentration in blood serum was 6.58 ±3.59 ng/ml. The mean percentage of body fat was 32.7 ±6.3 (range: 16.1-50.7). The percentages of women in particular groups of body fat level (I, II, III, IV and V) were 1.7%, 11%, 35.3%, 30.7% and 21.3% respectively. Myostatin level in blood serum was significantly lower (median concentrations: 5.5 vs. 7.0 ng/ml, p = 0.0269) in subjects with higher body fat (groups IV and V) compared to those classified as having a normal or low level of body fat (groups I-III). Myostatin was an independent predictive factor of the occurrence of high body fat (p = 0.0463).

CONCLUSIONS

Decreased level of myostatin is related to higher level of body fat in peri- and postmenopausal women.

Are there still sex differences in the functioning of the elderly?

Abstract Introduction: Sex is one of the demographic characteristics that better differentiates the independence of the elderly, despite this distinction not being consensual. Objective: To know the differences in functioning associated with sex in elderly people aged ≥ 65 years according to the International Classification of Functioning, Disability, and Health (ICF). Methods: This was an analytical and cross-sectional observational study with a sample of 451 subjects. The instruments were a sociodemographic questionnaire identical to a ICF checklist and the Biopsychosocial Assessment Method. The student t, Mann-Whitney, chi-square, and Spearman correlation tests were used considering p < 0.05. Results: The average age was between 79.5 ± 7.5 years with a female prevalence (62.1%). Of the 43 variables studied, sex differences were found in 17 (39.5%). In the personal factors, women showed greater vulnerability in conjugality (p ≤ 0.001), cohabitation (p = 0.037), and economic income (p = 0.002). Nonetheless, they showed healthier behaviors in all health-related habits. As for environmental factors and body functions, greater fragility was once again observed in women: the need for assistive devices (p ≤ 0.001) and urinary incontinence (p = 0.021). In activities/participation, differences were found in mobility, where women experienced more restrictions, whereas men were more dependent on washing/drying clothes in domestic life (p = 0.022). Conclusion: Women are more unprotected in social and economic areas, while men showed more vulnerability in habits related to health. These differences are linked to demographic issues related to longevity, cultural differences, and socialization, and differences regarding activities/participation tend to dilute between sexes.

Risk of overactive bladder associated with cholinesterase inhibitors in dementia

BACKGROUND

Although cholinesterase inhibitors (ChEIs) are the primary treatment for dementia, they are associated with overactive bladder (OAB), necessitating antimuscarinic use. Limited data exist regarding the risk of OAB across individual ChEIs in dementia. This study evaluated the risk of OAB associated with individual ChEIs in older adults with dementia.

METHODS

This was a new user retrospective cohort study using Medicare claims data involving Parts A, B, and D claims dataset from 2013 to 2015. The study included older adults (aged 65 and older) with a diagnosis of dementia using donepezil, galantamine, or rivastigmine. New ChEI claims were identified with a 6-month baseline washout period. Patients with OAB diagnosis or any antimuscarinic or mirabegron use in the baseline period were excluded. The primary outcome of interest was OAB diagnosis or prescription of antimuscarinics or mirabegron within 6 months of ChEI initiation. Multivariable cox proportional hazards regression with propensity scores (PS) as covariates and inverse probability of treatment weighting generated using generalized boosted models was used to assess the risk of OAB among donepezil, galantamine, and rivastigmine users.

RESULTS

The study included 524,975 older adults with dementia who were incident users of ChEIs (donepezil 80.72%, rivastigmine 16.41%, galantamine 2.87%). Overall, OAB diagnosis/antimuscarinic/mirabegron prescription was observed in 5.07% of the cohort within 6 months of ChEIs prescription. The Cox regression model with PS as covariate approach found that donepezil use increased the risk of OAB compared to rivastigmine (aHR, 1.13; 95% CI, 1.08-1.28; p < 0.0001). However, there was no differential risk of OAB between galantamine and rivastigmine. The findings were consistent with the generalized boosted models.

CONCLUSIONS

The study found that the risk of OAB varies across individual ChEIs with an increased risk of OAB with donepezil compared to rivastigmine. The study findings suggest the need to understand and manage medication-related morbidity in older adults with dementia.

Does preoperative locally applied estrogen treatment facilitate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse? A randomised controlled double-masked, placebo-controlled, multicentre study

OBJECTIVE

To evaluate whether locally applied vaginal estrogen affects prolapse-associated complaints compared with placebo treatment in postmenopausal women prior to surgical prolapse repair.

DESIGN

Randomised, double-masked, placebo-controlled, multicentre study.

SETTING

Urogynaecology unit at the Medical University of Vienna and University Hospital of Tulln.

POPULATION

Postmenopausal women with symptomatic pelvic organ prolapse and planned surgical prolapse repair.

METHODS

Women were randomly assigned local estrogen cream or placebo cream 6 weeks preoperatively.

MAIN OUTCOME MEASURES

The primary outcome was differences in subjective prolapse-associated complaints after 6 weeks of treatment prior to surgery, assessed with the comprehensive German pelvic floor questionnaire. Secondary outcomes included differences in other pelvic floor-associated complaints (bladder, bowel or sexual function).

RESULTS

Out of 120 women randomised, 103 (86%) remained for the final analysis. After 6 weeks of treatment the prolapse domain score did not differ between the estrogen and the placebo groups (4.4 ± 0.19 versus 4.6 ± 0.19; mean difference, -0.21; 95% CI -0.74 to 0.33; P = 0.445). Multivariate analysis, including only women receiving the intervention, showed that none of the confounding factors modified the response to estradiol.

CONCLUSIONS

These results demonstrate that preoperative locally applied estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse.

TWEETABLE ABSTRACT

Preoperative local estrogen does not ameliorate prolapse-associated symptoms in postmenopausal women with pelvic organ prolapse.

Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy

INTRODUCTION

It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy.

AIM

To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions.

MATERIALS AND METHODS

Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment.

CONCLUSIONS

The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

Low energy availability and impact sport participation as risk factors for urinary incontinence in female athletes

INTRODUCTION

Relative Energy Deficiency in Sport (RED-S) is a clinical syndrome that includes the many complex health and performance consequences of low energy availability (EA) in athletes, when there is insufficient caloric intake to meet exercise-related energy expenditure and to support basic physiologic functions. There is a high prevalence of urinary incontinence (UI) in female athletes and it is more common in female athletes than non-athletes. The objective of this study was to determine if low EA is associated with UI in a population of adolescent and young adult female athletes and to evaluate for an association between sport categories and UI.

MATERIAL AND METHODS

1000 nulliparous female patients, ages 15-30 years, presenting to a sports medicine subspecialty clinic, provided informed consent/assent to participate in a cross-sectional study involving a comprehensive survey, anthropomorphic measurements, and medical record review. Low EA was defined as meeting ≥1 criterion: self-reported history of eating disorder/disordered eating (ED/DE), and/or a high score on the Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), and/or a high score on the Eating Disorder Screen for Primary Care (ESP). UI was assessed using questions adapted from the International Consultation on Incontinence-Urinary Incontinence Short Form (ICIQ-UI-SF), questions regarding timing of UI onset/duration, and a binary question regarding UI during sport activities. A total of 36 sport types were included in the survey and sub-divided into categories.

RESULTS AND DISCUSSION

Of the 1000 female athletes surveyed, 165 (16.5%) reported a history of experiencing UI during athletic activities. ICIQ- UI-SF responses indicated that 14% (137/1000) of the cohort experienced slight incontinence, 4% (35/1000) moderate incontinence, and 2 athletes experienced severe incontinence. There was a significant difference between UI categories in age (p = 0.01), low EA (p < 0.001), and sport category (p < 0.001). Females who had low EA had twice the likelihood (OR = 1.97; 95% CI = 1.39 to 2.81; p < 0.001) of UI compared to those with adequate EA, controlling for sports category and menstrual dysfunction. Females who participated in high impact sports were 4.5 times more likely (OR = 4.47; 95% CI = 2.29 to 8.74; p < 0.001) to have had UI compared to females who participated in ball sports, controlling for EA and menstrual dysfunction.

CONCLUSIONS

UI during athletic activities is a common problem among nulliparous adolescent and young adult female athletes, occurring in 16.5% of female athletes surveyed. UI was significantly associated with low EA across all sport categories. Sport type was significantly associated with UI, with the highest impact sport group demonstrating a higher prevalence and symptom severity compared to other sport categories.

Genitourinary syndrome of menopause in Chinese perimenopausal and postmenopausal women

OBJECTIVE

The aim of this study was to investigate genitourinary syndrome of menopause (GSM) in a large cohort, analyzing the dependency on age and menopausal status and possible differences between non-hysterectomized and hysterectomized women.

METHODS

Data were assessed by validated questionnaires, collected over 2 years for all eligible women attending our 'Menopause Clinic' from 31 Chinese provinces. Simple and unconditional logistic regression analysis was used with adjustments by all analyzed factors.

RESULTS

A total of 4063 women (mean age 50.53 ± 6.57 years), 2107 perimenopausal and 1956 postmenopausal, were included. Almost all GSM symptoms were more frequent and severe in postmenopausal women. GSM was more frequent in hysterectomized women compared to non-hysterectomized women. Independent of menopausal status, low sexual interest (92.78%), urinary incontinence (91.65%) and vaginal dryness (91.60%) were the top three GSM symptoms. Most severe were low sexual interest (21.01%), vaginal pain (20.10%) and decreased sexual pleasure (17.13%). Prevalence and severity of GSM were not related to age, but were related to menopausal status and increased with time since menopause.

CONCLUSIONS

Within 2 years, more than 4000 women with GSM traveled from all over China to our specialized clinic, indicating the great importance of GSM. Hysterectomy can increase the risk of GSM, and GSM symptoms increase from perimenopause to postmenopause and with an increase of time since menopause, pointing to the dependency on the loss of ovarian function.

Impact of Menopausal Status on Uropathogen Prevalence and Antimicrobial Resistance Profiles

OBJECTIVES

The unique factors associated with urinary tract infections (UTIs) in postmenopausal (PMP) women have been significantly less investigated as compared with premenopausal (PreMP) women. Our objective was to compare the prevalence of uropathogens and antibiotic resistance patterns between PreMP and PMP women with UTIs.

METHODS

This was a cross-sectional analysis of PreMP and PMP women treated for a UTI in a urogynecologic practice between November 2016 and November 2017. Diagnostic criteria for UTI included lower urinary tract symptoms and a positive urine culture. Our primary outcome was proportion of non-Escherichia coli UTIs between groups.

RESULTS

We had 370 women with mean (SD) age of 66.7 (12.8) years and body mass index of 29.1 (7.1) kg/m2. Most women were PMP (88.6%). Postmenopausal status did not increase the proportion of non-E. coli UTI (42.7% PMP vs 33.3% PreMP, P = 0.25) or decrease the proportion of pansensitive UTI (36.0% PMP vs 42.9% PreMP, P = 0.38).In multivariable analysis, women with a history of rUTI were at higher odds of having a non-E. coli UTI (adjusted odds ratio, 1.93; 95% confidence interval, 1.21-3.08; P = 0.01) and at lower odds of pansensitive urine culture (adjusted odds ratio, 0.37; 95% confidence interval, 0.22-0.63; P < 0.01) as compared with those without rUTI, when controlling for confounders. Postmenopausal women with a history of rUTI had the highest proportion of non-E. coli UTIs (51.1%, P < 0.01) and lowest proportion of pansensitive uropathogens (29.1%, P < 0.01) as compared with other PMP women and PreMP without a history of rUTI.

CONCLUSIONS

In a urogynecologic population, a history of rUTI, more than menopausal status, significantly impacted the prevalence of specific uropathogens and resistant organisms.

Clinical outcomes and uroflowmetry assessment in patients with apical prolapse after laparoscopic uterosacral ligament suspension

OBJECTIVE

The aim was to evaluate the voiding function and voiding dysfunction 3 months after laparoscopic uterosacral ligament suspension (LUSLS). We identified risk factors for postoperative voiding dysfunction.

STUDY DESIGN

This retrospective study included 57 women with apical prolapse who underwent LUSLS with stage II or greater apical prolapse and without advanced anterior vaginal prolapse (stage III or IV). Data were collected from electronic medical records. Voiding function was assessed by uroflowmetry, PVR examination, and self-report questionnaires (the Pelvic Floor Distress Inventory-20 and the Urinary Impact Questionnaire) at baseline and 3 months after surgery. Voiding dysfunction was defined as an average flow rate (Qave)＜10 ml/s, a maximum flow rate (Qmax)＜15 ml/s, or a postvoid residual volume (PVR)＞50 ml. Statistical analyses were performed using paired-sample t tests, χ2 tests, and multivariate logistic regression.

RESULTS

Thirty-five percent of women suffered from voiding dysfunction preoperatively. Uroflowmetry parameters and PVR, objective symptoms including voiding difficulties, incomplete empty, frequency and urinary incontinence didn't show significant improvement postoperatively (all p＞0.05). Low Q_ave was identified as an independent risk factor of post voiding dysfunction (odds ratio, 0.558; 95 % CI, 0.324-0.963).

CONCLUSIONS

Approximately one-third of women suffering from apical prolapse without advanced anterior vaginal wall had evidence of voiding dysfunction preoperatively. LUSLS has no obvious effect on uroflowmetry parameters and clinical symptoms.

Three-dimensional ultrasound evaluation of the pelvic floor in postmenopausal women using hormone therapy

OBJECTIVE

To evaluate the three-dimensional (3D) ultrasound characteristics of the pelvic floor muscles (PFM) in two groups of postmenopausal women: users and nonusers of menopausal hormone therapy (MHT).

STUDY DESIGN

Observational, cross-sectional cohort study.

MAIN OUTCOME MEASURES

In this study 226 sexually active heterosexual women, aged 45-60 years with amenorrhea >12 months and without clinical pelvic floor disorders or urinary incontinence were included. Women using MHT ≥ 6 months were classified as systemic users. PFM strength was assessed by digital vaginal palpation and scored on the Modified Oxford Scale. Biometry of the PFM was performed by 3D transperineal ultrasound for evaluation of total urogenital hiatus area, transverse and anteroposterior diameters, and levator ani muscle thickness.

RESULTS

The participants were divided into users (n = 78) and nonusers (n = 148) of MHT. There were no differences in clinical or anthropometric parameters between groups. The mean age was 55 years and the time since menopause was six years in both groups. The mean duration of MHT use was 43.4 ± 33.3 months. Users of MHT had greater levator ani muscle thickness (p = 0.001) and higher PFM strength (p = 0.029) than nonusers. Risk analysis adjusted for age, time since menopause, BMI, parity, and type of delivery showed an association of MHT use with greater levator ani muscle thickness (OR = 2.69; 95% CI 1.42-5.11, p = 0.029), and higher PFM strength (OR = 1.78; 95% CI1.01-3.29, p = 0.046). There was a weak positive correlation between levator ani muscle thickness and duration of MHT use (r = 0.25, p = 0.0002) and PFM strength (r = 0.12, p = 0.043).

CONCLUSIONS

Postmenopausal women using MHT had a greater levator ani muscle thickness associated with higher PFM strength than nonusers.

Sporadic compared to recurrent urinary tract infections: Considerations for urogynecologic patients

AIMS

To describe the uropathogens and antimicrobial resistance patterns in women with singular, sporadic urinary tract infection (UTI) vs those with recurrent UTI (rUTI) in a urogynecologic population.

METHODS

This was a cross-sectional analysis of women treated for a UTI by a urogynecologic provider in a 1-year timeframe. Subjects were divided into two groups: (a) sporadic UTI-no history of rUTI and a single infection in the study timeframe and (b) rUTI-history of rUTI and ≥2 UTIs in the study timeframe. Our primary outcome was the difference in uropathogens between groups. Secondary aims were to investigate host characteristics associated with recurrent Escherichia coli infections and resistant uropathogens in the rUTI cohort.

RESULTS

We had 265 women with 163 (61.5%) in the sporadic UTI group and 102 (38.5%) in the rUTI group. The most common uropathogens were E. coli (57.3%) and Klebsiella (11.7%). In the rUTI group, only 27 of 102 (26.5%) had all E. coli infections. There were differences between groups regarding age (P = .03) and proportion of neurogenic bladder (P = .01), intermittent self-catheterization (P < .01), antibiotic suppression (P < .01), and vaginal estrogen therapy (P < .01). In the rUTI cohort, there were no risk factors that were significantly associated with recurrent E.coli UTIs and vaginal estrogen therapy was associated with a higher odds of sensitive uropathogens (adjusted odds ratio, 3.12; confidence interval, 1.28-7.56).

CONCLUSIONS

In those with rUTI, it was uncommon to have recurring E. coli UTIs and consistently sensitive uropathogens. Pretreatment urine cultures are important to verify causative uropathogens in this population.

Identification and management of urinary incontinence in midlife women

Urinary incontinence is a common bladder health problem that disproportionately affects women, especially midlife women. In the absence of alarming signs or symptoms, a step-wise evaluation aligned with patient treatment preferences is appropriate. Initial interventions can include simple behavior therapies, lifestyle modifications, and toileting habits. Systemic medication, surgery, and specialty treatment also can be offered.

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.

In Vitro Antioxidant and Bactericidal Efficacy of 15 Common Spices: Novel Therapeutics for Urinary Tract Infections?

Background and Objectives: Bacterial urinary tract infection (UTI) is the most common ailment affecting all age groups in males and females. The commercial antibiotics usage augments antibiotics resistance and creates higher recurrence rates of such communal infections. Hence, this study is aimed at investigating the antibacterial and antioxidant potentials of 15 common spices against 11 UTI-causing bacterial pathogens. Materials and Methods: The antioxidant potential of the methanolic extracts was analyzed as contents of total phenols and flavonoids; radical scavenging, total reducing power, the ferric reducing power assay. Urinary pathogens were subjected to spice extracts to investigate antibacterial assays. Results: Preliminary phytochemical study of spices was performed to find those containing alkaloids, flavonoids, phenolic compounds, and steroids that can be recognized for their noteworthy bactericidal effects. The outcome of the antioxidative potential from the four methods demonstrated the sequence of potent antioxidant activity: Acorus calamus >Alpinia galanga > Armoracia rusticana > Capparis spinosa > Aframomum melegueta. The total polyphenols and flavonoids in the studied species positively correlated with their antioxidant properties. The four most effective spices (A. calamus, A. galanga, A. rusticana, and C. spinosa) had a zone of inhibition of at least 22 mm. A. calamus, A. melegueta, and C. spinosa had the lowest minimum inhibitory concentration (MIC) value against Enterobacter aerogenes, Staphylococcus aureus and Proteus mirabilis. All 15 spices had the lowest minimum bactericidal concentration (MBC) value against most of the pathogenic bacteria. Conclusion: The four highly potent and unique spices noted for the in vitro control of UTI-causing pathogens could be pursued further in the development of complementary and alternative medicine against UTI-causing pathogens.