Treatment with oral piperazine oestrone sulphate for genuine stress incontinence in postmenopausal women

Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews

BACKGROUND

Urinary incontinence (UI) is the involuntary loss of urine and can be caused by several different conditions. The common types of UI are stress (SUI), urgency (UUI) and mixed (MUI). A wide range of interventions can be delivered to reduce the symptoms of UI in women. Conservative interventions are generally recommended as the first line of treatment.

OBJECTIVES

To summarise Cochrane Reviews that assessed the effects of conservative interventions for treating UI in women.

METHODS

We searched the Cochrane Library to January 2021 (CDSR; 2021, Issue 1) and included any Cochrane Review that included studies with women aged 18 years or older with a clinical diagnosis of SUI, UUI or MUI, and investigating a conservative intervention aimed at improving or curing UI. We included reviews that compared a conservative intervention with 'control' (which included placebo, no treatment or usual care), another conservative intervention or another active, but non-conservative, intervention. A stakeholder group informed the selection and synthesis of evidence. Two overview authors independently applied the inclusion criteria, extracted data and judged review quality, resolving disagreements through discussion. Primary outcomes of interest were patient-reported cure or improvement and condition-specific quality of life. We judged the risk of bias in included reviews using the ROBIS tool. We judged the certainty of evidence within the reviews based on the GRADE approach. Evidence relating to SUI, UUI or all types of UI combined (AUI) were synthesised separately. The AUI group included evidence relating to participants with MUI, as well as from studies that combined women with different diagnoses (i.e. SUI, UUI and MUI) and studies in which the type of UI was unclear.

MAIN RESULTS

We included 29 relevant Cochrane Reviews. Seven focused on physical therapies; five on education, behavioural and lifestyle advice; one on mechanical devices; one on acupuncture and one on yoga. Fourteen focused on non-conservative interventions but had a comparison with a conservative intervention. No reviews synthesised evidence relating to psychological therapies. There were 112 unique trials (including 8975 women) that had primary outcome data included in at least one analysis. Stress urinary incontinence (14 reviews) Conservative intervention versus control: there was moderate or high certainty evidence that pelvic floor muscle training (PFMT), PFMT plus biofeedback and cones were more beneficial than control for curing or improving UI. PFMT and intravaginal devices improved quality of life compared to control. One conservative intervention versus another conservative intervention: for cure and improvement of UI, there was moderate or high certainty evidence that: continence pessary plus PFMT was more beneficial than continence pessary alone; PFMT plus educational intervention was more beneficial than cones; more-intensive PFMT was more beneficial than less-intensive PFMT; and PFMT plus an adherence strategy was more beneficial than PFMT alone. There was no moderate or high certainty evidence for quality of life. Urgency urinary incontinence (five reviews) Conservative intervention versus control: there was moderate to high-certainty evidence demonstrating that PFMT plus feedback, PFMT plus biofeedback, electrical stimulation and bladder training were more beneficial than control for curing or improving UI. Women using electrical stimulation plus PFMT had higher quality of life than women in the control group. One conservative intervention versus another conservative intervention: for cure or improvement, there was moderate certainty evidence that electrical stimulation was more effective than laseropuncture. There was high or moderate certainty evidence that PFMT resulted in higher quality of life than electrical stimulation and electrical stimulation plus PFMT resulted in better cure or improvement and higher quality of life than PFMT alone. All types of urinary incontinence (13 reviews) Conservative intervention versus control: there was moderate to high certainty evidence of better cure or improvement with PFMT, electrical stimulation, weight loss and cones compared to control. There was moderate certainty evidence of improved quality of life with PFMT compared to control. One conservative intervention versus another conservative intervention: there was moderate or high certainty evidence of better cure or improvement for PFMT with bladder training than bladder training alone. Likewise, PFMT with more individual health professional supervision was more effective than less contact/supervision and more-intensive PFMT was more beneficial than less-intensive PFMT. There was moderate certainty evidence that PFMT plus bladder training resulted in higher quality of life than bladder training alone.

AUTHORS' CONCLUSIONS

There is high certainty that PFMT is more beneficial than control for all types of UI for outcomes of cure or improvement and quality of life. We are moderately certain that, if PFMT is more intense, more frequent, with individual supervision, with/without combined with behavioural interventions with/without an adherence strategy, effectiveness is improved. We are highly certain that, for cure or improvement, cones are more beneficial than control (but not PFMT) for women with SUI, electrical stimulation is beneficial for women with UUI, and weight loss results in more cure and improvement than control for women with AUI. Most evidence within the included Cochrane Reviews is of low certainty. It is important that future new and updated Cochrane Reviews develop questions that are more clinically useful, avoid multiple overlapping reviews and consult women with UI to further identify outcomes of importance.

The effect of hormones on the lower urinary tract

The female genital and lower urinary tracts share a common embryological origin, arising from the urogenital sinus and both are sensitive to the effects of the female sex steroid hormones throughout life. Estrogen is known to have an important role in the function of the lower urinary tract and estrogen and progesterone receptors have been demonstrated in the vagina, urethra, bladder and pelvic floor musculature. In addition estrogen deficiency occurring following the menopause is known to cause atrophic change and may be associated with lower urinary tract symptoms such as frequency, urgency, nocturia, urgency incontinence and recurrent infection. These may also co-exist with symptoms of urogenital atrophy such as dyspareunia, itching, vaginal burning and dryness. Epidemiological studies have implicated estrogen deficiency in the aetiology of lower urinary tract symptoms with 70% of women relating the onset of urinary incontinence to their final menstrual period. Whilst for many years systemic and vaginal estrogen therapy was felt to be beneficial in the treatment of lower urinary and genital tract symptoms this evidence has recently been challenged by large epidemiological studies investigating the use of systemic hormone replacement therapy as primary and secondary prevention of cardiovascular disease and osteoporosis. The aim of this paper is to examine the effect of the sex hormones, estrogen and progesterone, on the lower urinary tract and to review the current evidence regarding the role of systemic and vaginal estrogens in the management of lower urinary tract symptoms and urogenital atrophy.

Preventing urinary incontinence in women

PURPOSE OF REVIEW

This review examines the evidence to date, analyzes specific risk factors and assesses the ability to prevent urinary incontinence in women, while providing clinical recommendations. More extraordinary risk factors such as ethnicity and race, mixed and fecal incontinence, iatrogenic and neurogenic factors should be discussed in a follow-up report.

RECENT FINDINGS

Studies have revealed that certain factors place women at risk for developing urinary incontinence, including age, obesity, diabetes, pregnancy and delivery, high-impact physical exercise factors and estrogen deficiency.

SUMMARY

Healthcare providers should screen women who are at risk for developing urinary incontinence and institute specific interventions, specifically behavioral and even rehabilitative techniques, to prevent this prevalent and distressing condition.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women. This is an update of a Cochrane review first published in 2003 and subsequently updated in 2009.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 21 June 2012) which includes searches of MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for risk of bias and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed by grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty-four trials were identified which included approximately 19,676 incontinent women of whom 9599 received oestrogen therapy (1464 involved in trials of local vaginal oestrogen administration). Sample sizes of the studies ranged from 16 to 16,117 women. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.The combined result of six trials of systemic administration (of oral systemic oestrogens) resulted in worse incontinence than on placebo (risk ratio (RR) 1.32, 95% CI 1.17 to 1.48). This result was heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year. All of the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen were combined also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or pessaries) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.One small trial showed that women were more likely to have an improvement in incontinence after pelvic floor muscle training (PFMT) than with local oestrogen therapy (RR 2.30, 95% CI 1.50 to 3.52).The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Urinary incontinence may be improved with the use of local oestrogen treatment. However, there was little evidence from the trials on the period after oestrogen treatment had finished and no information about the long-term effects of this therapy was given. Conversely, systemic hormone replacement therapy using conjugated equine oestrogen may worsen incontinence. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence comparing routes of administration. The risk of endometrial and breast cancer after long-term use of systemic oestrogen suggests that treatment should be for limited periods, especially in those women with an intact uterus.

Estrogens and the lower urinary tract

The urogenital tract is sensitive to the effect of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of postmenopausal urinary incontinence remains controversial its use in the management of women complaining of urogenital atrophy is now well established. This aim of this paper is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of postmenopausal urinary incontinence, overactive bladder, recurrent lower urinary tract infections and urogenital atrophy. In addition to a review of the available evidence suggestions are also made regarding priorities for further research in the field.

[Conservative treatment of female stress urinary incontinence]

OBJECTIVES

To synthethise evidence based results related to non surgical management for urinary incontinence in women.

MATERIALS AND METHODS

Electronic search in Pubmed, Cinahl, Cochrane Library, National Library for Health.

RESULTS

There were 72 randomized control studies and 8 reviews from the Cochrane Library.

CONCLUSION

Moderate to high levels of evidence suggest that pelvic muscle training and bladder training may resolve urinary incontinence in women. A weight loss program from obesity state improve urinary continence. The effects of electrical stimulation of pelvic floor, oestrogene therapy were inconstant or inhomogeneous. Duloxetine may improve continence and quality of life but it's range in therapeutic algorithm is still to be defined.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register of trials (2 April 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty- three trials were identified which included 19,313 (1,262 involved in trials of local administration) incontinent women of whom 9417 received oestrogen therapy. Sample sizes ranged from 16 to 16,117. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.Systemic administration (of oral oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result is heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year; all the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen combined were used also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or tablets) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours and nocturnal voids amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus.

Urodynamic and morphologic changes in the lower portion of the urogenital tract after administration of estriol alone and in combination with phenylpropanolamine in sexually intact and spayed female dogs

OBJECTIVE

To compare the urodynamic and morphologic effects of the administration of estriol alone and in combination with phenylpropanolamine on the lower portion of the urogenital tract in female dogs.

ANIMALS

3 sexually intact and 3 spayed female Beagles without urinary incontinence.

PROCEDURE

Dogs received estriol (2 mg, PO) once daily for 7 days followed by estriol (2 mg, PO) and phenylpropanolamine (1.5 mg/kg, PO) once daily for 7 days. Urethral pressure profilometry, diuresis cystometry, and vaginourethrography were performed before treatment (day 0) and at days 7 and 14. The maximum urethral pressure (MUP) and closure pressure (MUCP), urethral functional and anatomic profile lengths, integrated pressure (IP), plateau, distance before MUP, maximum meatus pressure, threshold pressure, threshold volume, compliance, urethral length, and vaginal length and width were measured.

RESULTS

Before treatment, no urodynamic differences were observed between the 2 groups; however, vaginal length and width were significantly shorter in spayed dogs. Compared with day 0 values, estriol treatment significantly increased MUP, MUCP, and IP values at day 7, but at day 14, this effect decreased despite phenylpropanolamine administration. No morphologic changes from baseline were detected after either treatment in any dog.

CONCLUSIONS AND CLINICAL RELEVANCE

Data suggest that estriol mainly acts on the urethral sphincter mechanism by increasing urethral resistance in sexually intact and spayed female dogs without urinary incontinence. Administration of estriol and phenylpropanolamine did not increase the urethral resistance more than estriol alone. The urodynamic effects of estriol in female dogs with urinary incontinence remain to be elucidated.

The effect of ultralow-dose transdermal estradiol on urinary incontinence in postmenopausal women

OBJECTIVE

To estimate the effect of 2 years of treatment with ultralow-dose transdermal estradiol (E2) on incontinence in postmenopausal women.

METHODS

Ultra Low Dose Transdermal estRogen Assessment (ULTRA) was a multicenter, randomized, double-blinded, placebo-controlled trial of unopposed ultralow-dose (0.014 mg/d) transdermal E2 for prevention of osteoporosis in 417 postmenopausal women aged 60 to 80 years. Frequency of incontinence episodes was assessed at baseline and after 4 months and 2 years of treatment using a self-reported questionnaire. We used an intention-to-treat analysis to compare change in incontinence frequency, improved (decreased 2 or more episodes per week), unchanged (increased or decreased no more than 1 episode per week), or worsened (increased 2 or more episodes per week) between the E2 and placebo groups among women with and without at least weekly incontinence at baseline.

RESULTS

At baseline, the prevalence of at least weekly incontinence was similar between E2 and placebo groups (43%). After 2 years, there was no difference between groups in the proportions of women with incontinence at baseline whose incontinence improved, worsened, or was unchanged. The odds ratio for worsening incontinence in the E2 compared with placebo group was 1.35 (95% confidence interval 0.75-2.42. In women without incontinence at baseline, the odds of developing at least weekly incontinence after 2 years in the E2 compared with placebo group was not significant (odds ratio 1.2, 95% confidence interval 0.7-2.2).

CONCLUSION

Two years of treatment with unopposed ultralow-dose transdermal E2 did not substantially change the frequency of incontinence symptoms or alter the risk of developing at least weekly incontinence.

LEVEL OF EVIDENCE

I.

Postmenopausal hormone therapy: does it cause incontinence?

OBJECTIVE

To estimate the effect of hormone therapy on risk of stress and urge urinary incontinence.

METHODS

The Heart Estrogen/progestin Replacement Study was a randomized, placebo-controlled, double-blinded trial to evaluate daily oral conjugated estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) therapy for the prevention of heart disease events in women with established heart disease. The 1,208 participants in Heart Estrogen/progestin Replacement Study who reported no loss of urine in the previous 7 days at baseline are included in this analysis.

RESULTS

During 4.2 years of treatment, 64% of women randomly assigned to hormone therapy compared with 49% of those assigned to placebo reported weekly incontinence (P < .001). The higher risk of incontinence in the hormone group was evident at 4 months, persisted throughout the treatment period, and was independent of the age of the women. The odds ratios for weekly incontinence among women on hormone therapy compared with placebo were 1.5 for urge incontinence (95% confidence interval [CI] 1.2-1.8; P < .001) and 1.7 for stress incontinence (95% CI 1.5-2.1; P < .001). Four years of treatment with hormone therapy caused an excess risk of 12% for weekly urge incontinence and 16% for weekly stress incontinence; the corresponding numbers needed to harm were 8.6 (95% CI 5.8-16.6) and 6.2 (95% CI 4.6-9.4).

CONCLUSION

Estrogen plus progestin therapy increases risk of urge and stress incontinence within 4 months of beginning treatment.

LEVEL OF EVIDENCE

I.

Incidence of urinary incontinence in postmenopausal women treated with raloxifene or estrogen

OBJECTIVE

Determine the effect of raloxifene or estrogen, as compared with placebo, on the reporting of urinary incontinence in postmenopausal women participating in an osteoporosis prevention trial.

DESIGN

The current analysis is based on adverse event data that were collected as part of a double-blind, randomized, placebo-controlled trial designed to assess the efficacy and safety of raloxifene for osteoporosis prevention in postmenopausal women. Women were 40 to 60 years of age at study entry and had a prior hysterectomy. A total of 619 women were randomized to placebo, raloxifene 60 or 150 mg/d, or conjugated equine estrogen 0.625 mg/d and followed for up to 3 years. Urinary incontinence was self-reported and rated by participants as "mild," "moderate," or "severe."

RESULTS

The prevalence of urinary incontinence as reported by patients at baseline was similar across treatment groups (3% to 6%, P = 0.46). During 3 years of follow-up, new or worsening urinary incontinence was reported with the following frequency: placebo (1.3%), raloxifene 60 mg/d (0.7%), raloxifene 150 mg/d (0.6%), and conjugated equine estrogen (7.0%). The percentage of estrogen subjects reporting urinary incontinence was significantly greater than that for placebo and both doses of raloxifene (P < or = 0.02).

CONCLUSION

During 3 years of follow-up, conjugated equine estrogen was associated with an increased incidence of reports of urinary incontinence in women with a prior hysterectomy and this was significantly greater than both placebo and raloxifene.

CEU:Managing menopausal symptoms after the women's health initiative

Until the results of the Women's Health Initiative (WHI) were released in July 2002, hormone replacement therapy (HRT) had been thought to be the most effective way to manage unwanted menopausal symptoms and to prevent long-term health problems associated with aging. The results of the WHI, showing that HRT is less beneficial and associated with more risks than previously thought, has complicated the management of unwanted menopausal symptoms. This article discusses the effectiveness of HRT and other modalities used to relieve menopausal symptoms and discusses how to choose an HRT product to match specific menopausal complaints and provide maximum safety.

The role of estrogens in female lower urinary tract dysfunction

The urogenital tract and lower urinary tract are sensitive to the effects of estrogen and progesterone throughout adult life. Epidemiologic studies have implicated estrogen deficiency in the etiology of lower urinary tract symptoms that occur after menopause. Although the role of estrogen replacement therapy in the management of postmenopausal urinary incontinence (UI) remains controversial, its use in the treatment of women with urogenital atrophy is now well established. This review summarizes recent evidence of the urogenital effects of hormone therapy, particularly emphasizing management of postmenopausal UI and recurrent lower urinary tract infections. Estrogen therapy alone has little effect in the management of urodynamic stress UI, although in combination with an alpha-adrenergic agonist, it may improve urinary leakage. Estrogen therapy may be of benefit for the irritative symptoms of urinary urgency, frequency, and urge UI, although this effect may result from reversal of urogenital atrophy rather than a direct action on the lower urinary tract. The role of estrogen replacement therapy in the treatment of women with recurrent lower urinary tract infections remains to be determined, although there is now some evidence that vaginal administration may be efficacious. Low-dose, vaginally administered estrogens have a role in the treatment of urogenital atrophy in postmenopausal women and appear to be as effective as systemic preparations.

What is the available evidence for hormone replacement therapy in women with stress urinary incontinence?

OBJECTIVE

To examine the evidence for the effectiveness of estrogen replacement therapy, with or without progesterone, for the treatment of stress urinary incontinence (SUI) in hypoestrogenic women.

METHODS

MEDLINE, DARE, CINAHL, Cochrane Central Register of Controlled Trials, and EMBASE databases were searched for studies, in all languages, that used estrogen therapy, with or without progesterone, in hypoestrogenic women with SUI. The following key words were used in the search: estrogen, hormone replacement therapy, female urinary incontinence, stress urinary incontinence, and urodynamic stress incontinence. Studies that did not specify a subgroup with SUI among women with mixed incontinence were excluded.

RESULTS

Of the papers included in this evaluation, 14 were non-randomized studies of estrogen treatment with or without progesterone; 6 were randomized trials of estrogen alone, combined with other treatments; 4 were placebo-controlled randomized trials, 2 of which were with progesterone; and 2 were meta-analyses. A symptomatic or clinical improvement was detected only in nonrandomized studies; randomized trials did not suggest a benefit of estrogen therapy, with or without progesterone, among postmenopausal women with SUI.

CONCLUSIONS

Further research, ideally randomized placebo-controlled trials, is required to determine the risks and benefits of estrogen treatment alone in the management of SUI in postmenopausal women.

The menopause and HRT. Urogenital effects of hormone therapy

The urogenital tract and lower urinary tract are sensitive to the effects of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of post-menopausal urinary incontinence remains controversial, its use in the management of women complaining of urogenital atrophy is now well established. This aim of this chapter is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of post-menopausal urinary incontinence, recurrent lower urinary tract infections and urogenital atrophy.

Oestrogens for urinary incontinence in women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (November 2002) and the reference lists of relevant articles. Date of the most recent searches: November 2002.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urge or mixed incontinence or other urinary symptoms.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the reviewers. Data were extracted by all three reviewers and cross checked. Trial results were analysed within clinical subgroups or by intervention. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Twenty eight trials were identified which included 2926 women. Sample sizes ranged from 16 to 1525. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of trials. In the 15 trials that compared oestrogen with placebo, 374 women received oestrogen and 344 placebo. Subjective impression of cure was higher amongst those treated with oestrogen for all categories of incontinence (36/101, 36% versus 20/96, 21%; RR for cure 1.61, 95% CI: 1.04 to 2.49). When subjective cure and improvement were considered together, a statistically higher cure and improvement rate was shown for both urge (35/61, 57% versus 16/58, 28% on placebo) and stress (46/107, 43% versus 29/109, 27%) incontinence. For women with urge incontinence, the chance of cure or improvement was approximately a quarter higher again than in women with stress incontinence. Taking all trials together, the data suggested that about 50% of women treated with oestrogen were cured or improved compared with about 25% on placebo. Overall, there were around 1 to 2 fewer voids in 24 hours amongst women treated with oestrogen. The effect again appeared to be larger amongst women with urge incontinence. There were no statistically significant differences in respect of frequency, nocturia or urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea. In a large trial conducted amongst women with heart disease, data from a subset who had incontinence suggested that women treated with a combination of oestrogen and a progestogen had lower subjective cure or improvement rates compared to the placebo group (RR 0.85, 95% CI 0.76 to 0.95). The data were too few to address other questions about oestrogens compared with, or in combination with, other treatments, different types of oestrogen or different modes of delivery.

REVIEWER'S CONCLUSIONS

Oestrogen treatment can improve or cure incontinence and the evidence suggests that this is more likely with urge incontinence. There was little evidence from the trials after oestrogen treatment had finished and none about long-term effects. Combined oestrogen and progesterone appeared to reduce the likelihood of cure or improvement. There were too few data to address reliably other aspects of oestrogen therapy such as oestrogen type, dose and route of administration. However, the risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in women with an intact uterus.

Quality of life and menopause: the role of estrogen

The use of estrogen or hormone replacement therapy (ERT/HRT) in preventing disease in menopausal women has been well documented. Less attention has been paid to the menopausal symptoms that can impair the quality of life of menopausal women, such as hot flushes, sleep disorders, sexual dysfunction, and alterations in mood. Researchers have used a variety of methods to investigate these concerns. Decreases in ovarian hormones that occur with menopause have been implicated in these symptoms. Ovarian hormones affect the central nervous system and urogenital tissues directly via receptors for estrogen, progesterone, and androgens. Changes in the symptoms of menopause consequential to estrogen therapy reflect the effect of this therapy on these tissues. Evidence supporting the effectiveness of ERT/HRT in the treatment of symptoms affecting quality of life is growing and supports the use of ERT/HRT during menopause. Because the most dramatic hormonal changes associated with menopause are related to estrogen and because estrogen is usually coadministered with a progestogen in patients with an intact uterus, this review is focused primarily on ERT/HRT. Because androgen therapy may also improve quality of life by enhancing perimenopausal and postmenopausal sexual desire, function, and general well-being, a brief discussion of androgen supplementation of ERT/HRT is also included. The ideal doses and combinations of hormones must be determined on an individual basis, taking into consideration benefits, risks, and interactions of the different hormone therapies.

The effect of ovariectomy and long-term estrogen replacement on bladder structure and function in the rat

PURPOSE The use of estrogen replacement therapy for treating postmenopausal urinary incontinence is a controversial topic. We examined the behavioral, cystometric and histological changes that occur with long-term estrogen depletion and supplementation in rat bladders to determine the role of menopause in lower urinary tract dysfunction. MATERIALS AND METHODS A total of 40 female Sprague-Dawley rats were placed into 1 of 3 groups, including bilateral ovariectomy, bilateral ovariectomy plus estrogen replacement and control. The estrogen replaced group received a 0.25 mg. 16-week sustained release pellet (Innovative Research of America, Sanasota, Florida) placed subcutaneously. After surgery voiding frequency and volume were measured in 24-hour periods by placing animals in metabolic cages. After 16 weeks the rats underwent catheterization and continuous cystometry. The bladder was then removed and stained with Gomori trichrome. The collagen-to-smooth muscle density ratio was calculated for each specimen using current imaging software. RESULTS There was no significant difference in voiding patterns in the 3 groups, as measured by volume and voiding frequency. Cystometric data showed a trend toward higher voiding pressure, threshold pressure, baseline pressure and mean inter-voiding pressure in the ovariectomy group compared with the estrogen and control groups, although there was no statistical significance. Histological studies showed a higher mean collagen-to-smooth muscle ratio plus or minus standard deviation in the ovariectomy group (0.807 +/- 0.204) than in the ovariectomy plus estrogen replacement (0.709 +/- 0.118) and control (0.700 +/- 0.129) groups (p <0.05). Furthermore, when histological and cystometric data were compared for individual samples, we found a direct correlation of mean inter-voiding pressure (a measure of bladder instability) with the collagen-to-smooth muscle ratio (p <0.05). CONCLUSIONS Long-term estrogen replacement is beneficial for treating postmenopausal urinary incontinence.

P2X(3) receptor subunit messenger RNA expression in the female mouse bladder after oophorectomy with or without estrogen replacement

OBJECTIVE

This investigation was undertaken to determine whether the sensory neuron adenosine triphosphate receptor subunit (P2X(3)) messenger RNA expression is altered in female mouse bladders after surgical oophorectomy with or without estrogen replacement.

STUDY DESIGN

The mean relative concentrations of the P2X(3) receptor in 30 female mouse bladders (10 sham operated, 10 oophorectomized, and 10 oophorectomized with estrogen replacement) were determined with quantitative reverse transcription-polymerase chain reaction analysis.

RESULTS

P2X(3) expression increased after surgical oophorectomy (0.91 +/- 0.16 vs 1.04 +/- 0.11, P =.048). However, P2X(3) expression after oophorectomy and immediate estrogen replacement did not differ from that of oophorectomy alone (1.11 +/- 0.15 vs 1.04 +/- 0.11, P =.206).

CONCLUSIONS

The P2X(3) sensory neuron receptor messenger RNA expression is increased after oophorectomy but is not influenced by subsequent estrogen replacement. This has clinical significance because sensory neuron receptors may be associated with certain forms of bladder dysfunction.

The influence of ovariectomy and estrogen replacement on voiding patterns and detrusor muscarinic receptor affinity in the rat

A rat model of ovariectomy-induced voiding dysfunction was established and the effects of ovariectomy and subsequent estrogen replacement on the affinity of muscarinic receptors in the rat bladder were determined. Voiding frequency and spatial distribution patterns were documented in sham-operated (control), and ovariectomized (placebo- or estrogen-treated) rats. The ovariectomized rats had a significantly different urinating pattern, i.e. higher voiding frequency and less peripheral voiding than the sham-operated group, suggestive of urge incontinence. Using this model of voiding dysfunction, negative logs of dissociation constants of carbachol of the rat detrusor muscarinic receptors were then determined indirectly using the Furchgott's double-reciprocal method. Receptor affinities were not significantly different in all groups compared to control females. In conclusion, a model of ovariectomy-induced voiding dysfunction in ovariectomized rats was established, where bladder dysfunction occurred with no significant changes in the affinity of muscarinic receptors.

The feasibility of urethral color ultrasound imaging in the diagnosis of female intrinsic sphincter deficiency: preliminary results

STUDY DESIGN

Prospective study.

OBJECTIVES

To evaluate the feasibility of color ultrasound imaging of the urethra in association with UPP to diagnose intrinsic sphincter deficiency (ISD).

SETTING

Italy.

METHODS

We studied a group of 13 normal female volunteers (mean age 29 years) during the estrogenic phase and a group of 15 patients (mean age 63.9 years) with ISD. All patients and normal volunteers underwent color ultrasound imaging using a 4-7 MHz convex broad band transducer. Translabial sagittal scans of the urethra were obtained. The color ultrasound parameters were optimized for detection of parenchymal slow flows. A subjective score of the degree of vascularization along the entire urethra was established as follows: (a) minimal or absent (1), (b) poor (2), (c) moderate (3), (d) good (4). Statistical analysis, using the non-parametric Mann-Whitney rank sum test, was carried out to determine differences of ultrasound scores between volunteers and patients.

RESULTS

The statistical evaluation showed that the differences between the ultrasound scores in the two groups was statistically significant (P<0.001).

CONCLUSION

We affirm that color ultrasound imaging of the urethra seems to be feasible and useful in association with UPP in the diagnosis of ISD even if this echographic investigation needs further observations.

Estrogen, progesterone, and androgen receptor expression in levator ani muscle and fascia

Previous studies have reported controversial data on estrogen receptor (ER) expression in levator ani muscle. We investigated ER expression in levator ani muscle and fascia and compared it with the expression of progesterone receptor (PR) and androgen receptor (AR). The study included 55 women undergoing surgery for gynecological (asymptomatic, n = 10) or urogynecological conditions (symptomatic, n = 45). The asymptomatic and 21 of the symptomatic women received no hormone replacement therapy (HRT). The remaining 24 symptomatic women received some form of HRT. Biopsies were taken from the levator ani muscle and the overlying fascia, and quantitative measurements of immunohistochemical staining by image analysis were made. None of the levator ani muscle samples showed any evidence of nuclear ER expression in striated muscle fibers, but some cells in the muscular stroma did express ER. However, PR and AR expression was found in both muscle and stromal cells. Levator ani fascia showed nuclear ER, PR, and AR expression to varying degrees. There was a significant increase (p < 0.03) in ER expression in levator ani fascia of symptomatic patients without HRT when compared with asymptomatic age-matched women. The ER expression was significantly lower (p < 0.001) in postmenopausal symptomatic women receiving long-term estrogen replacement compared with age-matched women without HRT. Our data indicate that ER expression is significantly higher in symptomatic women compared with age-matched asymptomatic females. However, long-term estrogenization causes significant decrease of ER expression.

Colour Doppler ultrasonography of female urethral vascularization in normal young volunteers: a preliminary report

OBJECTIVE

To assess urethral vascularization in healthy young women, using colour Doppler ultrasonography.

SUBJECTS AND METHODS

Eleven healthy young women volunteers (mean age 33.6 years, range 24-46) with no pelvic floor disorders and no history of incontinence were assessed. The subjects underwent colour Doppler ultrasonography using a 4-7 MHz convex broadband transducer. Translabial sagittal scans of the urethra were taken when the subjects had a full bladder, both during the oestrogenic and progestogenic phases. The colour Doppler ultrasonography parameters were optimized to detect slow flows in the anterior and posterior distal, middle and proximal urethra. A rank-sum nonparametric test was used to assess differences between the resistive indices.

RESULTS

The statistical evaluation showed a significant difference in the resistive index only in the anterior urethra, between the distal and middle plus proximal urethra, in both the progestogenic (P = 0.002) and oestrogenic (P = 0.0127) phases.

CONCLUSIONS

This study confirmed that the vascularization of the urethra plays an important role in the 'seal' effect, which is considered one of the most important factors in urethral closure. There was a significantly greater resistive index in the anterior proximal urethra than in the middle and distal urethra. These findings suggest that the seal effect is related to the existence of a rich venous urethral vascularization, involved in the mechanism of urethral closure. Colour Doppler ultrasonography of the urethra seems to be feasible and useful for understanding the mechanism of the vascular component in female continence.

Oestrogen and progesterone receptor expression in the female lower urinary tract, with reference to oestrogen status

OBJECTIVE

To assess the incidence and distribution of both oestrogen and progesterone receptors throughout the female lower urinary tract, and to compare receptor expression in women of varying oestrogen status.

PATIENTS AND METHODS

The study included 90 women undergoing surgery for urogynaecological conditions; 33 were premenopausal, 26 postmenopausal and taking no oestrogen supplementation, and 31 postmenopausal and receiving some form of hormone-replacement therapy. Biopsies were taken during surgery from the bladder dome, trigone, proximal urethra, distal urethra, vagina and vesicovaginal fascia in the region of the bladder neck. All biopsies were routinely fixed and processed for histopathological assessment, and were then labelled immunohistochemically with monoclonal antibodies directed against human oestrogen (NCL-ERLH2) and progesterone (NCL-PGR) receptors. Both oestrogen and progesterone receptor expression were assessed in the epithelial, subepithelial and muscle/deeper fascial regions of all tissue for overall tissue positivity for each receptor, and by semiquantitative analysis of receptor concentration using histochemical scoring of the tissues.

RESULTS

Oestrogen receptors were consistently detected in the squamous epithelia and were consistently absent in the urothelial tissues of the lower urinary tract of all women irrespective of oestrogen status; there was no significant variation in histological score. Progesterone receptor expression was more variable, being mostly subepithelial, and significantly lower in postmenopausal women receiving no oestrogen replacement.

CONCLUSION

These findings confirm the female lower urinary tract to be a target organ for the action of oestrogen and progesterone, and shed further light on the areas of the lower urinary tract likely to respond to hormone-replacement therapy. This may have implications for the use of oestrogen supplementation in the treatment of lower urinary tract disorders of postmenopausal women.

Micturition complaints in postmenopausal women treated with continuously combined hormone replacement therapy: a prospective study

OBJECTIVES

To study parameters of the micturition pattern in postmenopausal women and the effect of an oral continuously combined HRT-regimen.

METHODS

Hormone therapy consisted of 2 mg 17 beta-oestradiol in combination with either 2.5, 5, 10 or 15 mg dydrogesterone, orally once a day. The baseline assessment was done just before starting hormone replacement therapy, the second assessment took place after 6 months of hormone therapy. Data were collected using a standardized questionnaire and focused on diurnal urinary frequency, nocturnal urinary frequency and urinary incontinence as parameters of the micturition pattern. Furthermore, bacteriuria was assessed.

RESULTS

One hundred and two women entered the study and 95 women completed 6 months of hormone replacement therapy. Urinary incontinence was reported by 44.1% of the women, in 19.6% of the women it occurred more than twice a week. Both diurnal frequency and nocturnal frequency was reported by 28.4% of the women. For women with frequency or nocturia, the number of voids significantly decreased after 6 months hormone replacement therapy. Nocturia disappeared in 65.4% of the women after treatment and 23.3% reported to be cured of their urinary incontinence. Bacteriuria was present in the same seven women before and after hormone treatment. Dydrogesterone dose did not influence treatment outcomes.

CONCLUSIONS

Postmenopausal women report improvement on urinary incontinence and nocturia after 6 months of a continuously combined hormone replacement therapy regimen. The improvement was most outspoken with regard to nocturia. Bacteriuria was not influenced. Different doses of dydrogesterone did not effect these findings.

Pharmacologic management of pelvic floor dysfunction

Pharmacologic therapy is an important part of the treatment armamentarium for urogynecologic disorders. Current and future research will determine the utility of such therapy as medications with fewer side effects and more targeted efficacy are developed.

Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiologic literature

OBJECTIVES

To review and integrate the current literature on the role of reproductive factors in the development of urinary incontinence in later life.

DESIGN

An extensive literature review using Medline and Science Citation Index for the period 1966 through 1997 was undertaken to identify published studies of the association between parturition events, hysterectomy, menopause, estrogen therapy, and later urinary incontinence.

RESULTS

Vaginal delivery is an established risk factor for both transient postpartum incontinence and the development of incontinence in later life. Several studies have found evidence of nerve and muscle damage that provide a physiologic basis for this association. Prospective studies of incontinence after hysterectomy have generally found no increased risk in the first few years. In contrast, cross-sectional epidemiologic studies have consistently found an increased risk many years after hysterectomy. Although menopause is often considered a risk factor for urinary incontinence, epidemiological studies have generally not found an increase in the prevalence of incontinence in the perimenopausal period. Oral estrogen replacement therapy seems to have little short-term clinical benefit in regard to incontinence and is associated consistently with increased risk of incontinence in women aged 60 years and older in epidemiologic studies.

CONCLUSIONS

This review provides a framework for further investigation of the complex relationships between reproductive risk factors and urinary incontinence. Integration of physiologic, clinical, and epidemiologic studies is needed to address the compelling health care issue of urinary incontinence. Suggestions are made for further areas of research.

Physiologic effects of steroid hormones and postmenopausal hormone replacement on the female breast and breast cancer risk

Most data demonstrate that breast cancer is hormonally influenced. For the woman with no history of breast cancer, the benefits of HRT may outweigh the risks. Although it remains the standard of care to discourage hormone use in patients who have had breast cancer, future studies may result in a change of this standard. There needs to be more research into these complex hormonal interactions so that we will have a better understanding of the true risks and benefits when we attempt to advise our patients regarding the best treatment regimens for them.

Urogenital aging--creation of improved awareness

Urogenital aging is given a low priority in the medical community and is an entity not well known to the general public. Many women are not aware of the possible disorders of the lower urinary tract and the vagina because of estrogen deficiency. These changes are perceived often as a normal part of the general aging process not associated with the possibility of medical attention, diagnosis, and treatment. Access to the information that certain urogenital dysfunctions, in particular incontinence, and vaginal discomfort respond to estrogen replacement therapy is not available for every woman. In addition, physicians and patients may hesitate to address these issues because of feelings of shame and embarrassment, feelings commonly encountered and specific for the complex of urogenital aging. Educational efforts and promotion of information with use of various media might help to improve knowledge and remove the taboo attached to urogenital aging in both health care providers and the general public. Thus a better understanding of urogenital aging would be achieved and the potential of estrogen replacement extended.

The menopause transition

New paradigms for the study of menopause will increase our understanding of whether symptoms, syndromes, and chronic diseases are associated with menopause. Rather than considering menopause as a discrete event, it has become clear that the menopause transition takes place over many years. Although this realization is central to our understanding of menopause, it is difficult to measure the temporal pattern of changes in hormones and their relation to concurrent or subsequent health-related events. The model of hormonal changes at the time of the transition has been expanded to include not only declines in estrogen but changes in a broader range of hormones, including the potential role of androgens. New models are attempting to account for the pattern and frequency of changes in hormone levels. Another level of complexity is contributed by the expansion of the menopause model to include comorbid medical and psychiatric conditions, environmental influences, and behaviors as covariates that influence the expression of menopause-related events. Although this more complicated paradigm makes the conduct of menopause research more challenging, it is also likely to elucidate previously confusing data, as the proper understanding of potentially complex exposures, effect modifiers, and confounders is more likely to provide clearer answers to critical research questions.

The role of estrogen replacement therapy in the management of urinary incontinence and urinary tract infection in postmenopausal women

The hormonal changes associated with normal aging and menopause may contribute to the development of urinary disorders including both urinary incontinence and urinary tract infections. Estrogen replacement therapy has been used successfully in the treatment of both of these disorders in postmenopausal women. Although the selection of specific treatment modalities should be tailored to the individual patient, hormonal replacement should be considered a viable conservative treatment option for many older women with urinary complaints. Future research will help to delineate the most effective route of administration and type of estrogen used in treating these complaints.

Anorectal manometry before, during and after estrogen replacement therapy

The incidence of relaxation of the pelvic floor increases with age, and although a relation between prolapse and the decline of estrogens has been suggested, there is no objective evidence. Together with urodynamic measurements, anal manometry is one of the few ways of making an objective assessment of the strength of pelvic structures located in and near the pelvic floor. In order to study the role of estrogens, anal manometry was performed before, during and after estrogen replacement therapy with daily oral use of 0.625 mg conjugated estrogens for 6 months. Five postmenopausal women, who had not used estrogen replacement therapy in the past, were included in the study. None of the manometric parameters, including maximal anal resting pressure, maximal squeeze pressure and internal anal sphincter response, changed. It was concluded that estrogens have no effects on manometric parameters of the external sphincter and that anal manometry may not be the appropriate method to assess the effects of estrogens on the pelvic floor.

Transdermal estrogen for female stress urinary incontinence in postmenopause

OBJECTIVE

To evaluate the effect of transdermal estrogen for stress urinary incontinence in postmenopause.

STUDY DESIGN

An open within patient, dose-finding study with transdermal 17-beta-estradiol combined with cyclic medroxyprogesterone acetate was conducted over 9 months in 21 patients (mean age 57.3 years) suffering from urodynamically verified mild to moderate stress incontinence without detrusor instability.

RESULTS

Subjective improvement was noted in 16 out of 21 patients (76%). The dose level of 50 micrograms was better tolerated than 100 micrograms and sufficient enough to achieve continence.

CONCLUSION

Transdermal estrogen therapy plays an adjuvant role in conservative therapy for mild to moderate stress urinary incontinence in postmenopausal women.

Menopausal genuine stress urinary incontinence treated with conjugated estrogens plus progestogens

OBJECTIVE

The aim of the study was to investigate clinically and urodynamically the effects of hormonal replacement in the treatment of genuine stress urinary incontinence in postmenopausal females.

METHODS

Clinical and urodynamic variables of 30 postmenopausal women with genuine stress urinary incontinence were evaluated after 3 months' treatment with conjugated estrogens plus progestogens. Urodynamic evaluations were performed in all patients before and after treatment.

RESULTS

Forty-six percent of the patients treated medically were judged to be cured and 43% were judged to be markedly improved. Maximum urethral closure pressure, maximum cystometric capacity and mean flow were significantly increased. Residual urine and diurnal and nocturnal voluntary micturition were markedly decreased (P < 0.05).

CONCLUSION

We conclude that hormone replacement in the form of conjugated estrogens plus progestogens results in the clinical and urodynamic improvement of genuine stress urinary incontinence in postmenopausal women.

Sex hormones, the menopause and urinary problems

To date, there have been few appropriate placebo-controlled studies using both subjective and objective parameters to assess the efficacy of estrogen therapy for the treatment of urinary incontinence. Further confusion arises from the heterogeneity of different study protocols. Consequently, the best treatment in terms of type and dose of estrogen and route of administration is unknown. From these studies, however, there is clear evidence to suggest that recurrent urinary tract infection can be prevented or even treated by the use of estrogen therapy. Furthermore, systemic estrogen replacement appears to alleviate the symptoms of urgency, urge incontinence, frequency, nocturia and dysuria, and low-dose topical estrogen is effective in the management of atrophic vaginitis. Although the latter example appears to be free from side-effects, even following prolonged administration, it is unclear whether low-dose therapy has a sufficient effect on the lower urinary tract to treat urinary incontinence. There is no conclusive evidence that estrogen replacement alone is sufficient to cure stress incontinence, but in combination with an alpha-adrenergic agonist there may be a role for estrogen therapy in the conservative management of genuine stress incontinence. On the other hand, estrogen supplementation definitely improves the quality of life of many postmenopausal women and, therefore, makes them better able to cope with other disabilities. Perhaps the role of estrogen in the management of postmenopausal urinary disorders is as an adjunct to other methods of treatment such as surgery, physiotherapy and drugs. This is certainly a hypothesis which should be tested.

Location and concentration of estrogen, progesterone, and androgen receptors in the bladder and urethra of the rabbit

The objective of this study was to determine location and concentration of estrogen, androgen, and progesterone receptors in the bladder and urethra of the rabbit. Two urethral and two bladder specimens were obtained from four 12-week-old female New Zealand white rabbits. Rat monoclonal antibody (AN1-15) to human androgen receptor and (H222) to human estrogen receptor and mouse monoclonal antibody (PR6) to chicken progesterone receptor were used. Immunocytochemical staining was performed and specimens were evaluated for presence and location of steroid receptors. Androgen receptors were found in the highest concentrations in urethral and bladder epithelium. Low to low/moderate concentration were found in smooth muscle. Estrogen receptors were found in moderate to moderate/high concentrations in urethral epithelium and bladder and urethral smooth muscle. Progesterone receptors were not found in appreciable concentrations from any location, though the animals were not pretreated with estrogen. The rabbit model suggests a mechanism by which estrogen therapy can be effective in treating postmenopausal lower urinary tract symptoms. Progesterone receptors were not found in appreciable concentrations, suggesting progesterone therapy may not diminish the effectiveness of estrogen therapy by acting on urethral progesterone receptors. The effect of androgens on the lower urinary tract needs further investigation to determine if androgen therapy can alleviate lower urinary tract symptoms.

Estrogen and urinary incontinence in women

OBJECTIVE

The purpose of this study was to review the efficacy of estrogen therapy for urinary incontinence by examining published trials and to review the epidemiologic and physiologic evidence for its action.

DATA SOURCES

Controlled and uncontrolled trials of estrogen therapy in the English literature were collected. Eight controlled and 14 uncontrolled trials were identified.

METHODS OF STUDY SELECTION

Trials were selected if they were prospective. All types of estrogen treatment were included. All types of outcome measurements were included.

DATA EXTRACTION AND SYNTHESIS

Trials were categorized by type of estrogen used; outcome variables (subjective improvement vs objective urodynamic data); and cure/improvement rates.

CONCLUSIONS

Published trials do not support estrogen replacement as efficacious therapy for stress urinary incontinence. It may be useful for incontinence associated with urgency and frequency. Adequately large controlled trials that evaluate estrogen replacement regimens used in the USA remain to be done.