The impact of the menstrual cycle on urinary symptoms and the results of urodynamic investigation

Polycystic Ovary Syndrome and Pelvic Floor Dysfunction: A Narrative Review

Pelvic floor dysfunction is one of the most common disorders in women that is associated with social and economic consequences. In general, this disorder imposes direct and indirect costs on the economy of various societies. This review aimed to investigate pelvic floor dysfunction in women with polycystic ovary syndrome (PCOS). In this narrative review, the published articles on pelvic floor dysfunction were examined in PubMed, Scopus, Web of Sciences and Google Scholar. We searched for terms related to polycystic ovary syndrome and pelvic floor dysfunction. Inclusion criteria of this research were observational, experimental, and review studies. In this investigation, the complications associated with polycystic ovary syndrome were examined as risk factors for pelvic floor dysfunction. In this narrative review, we discuss about changes in hormone levels, obesity and overweight, hormonal medications and complications such as diabetes and metabolic disorders and obstetric complications of PCOS can be involved in the pathophysiology of pelvic floor dysfunctions, including stress urinary incontinence and pelvic organ prolapse in women with PCOS. This review highlights knowledge gaps about protective effect of hyperandrogenism on pelvic floor dysfunction as well as destructive effect of metabolic changes on pelvic floor dysfunction in women with PCOS. Further cohort and prospective studies are recommended in women with PCOS to investigate the concept of pelvic organ dysfunction in these women.

Association between menopausal transition stages and developing urinary incontinence

OBJECTIVE

To estimate whether menopause transition stage is independently associated with the development of incontinence symptoms.

METHODS

We conducted a longitudinal analysis, using discrete proportional hazards models, of women who were continent at baseline in the Study of Women's Health Across the Nation (SWAN), a multicenter, multiracial, multiethnic prospective cohort study of community-dwelling midlife women transitioning through menopause. At baseline and each of the six annual visits, SWAN elicited frequency and type of incontinence in a self- administered questionnaire and classified menopausal stage from menstrual bleeding patterns.

RESULTS

Compared with premenopause, being in the early perimenopause (incidence 17.8 per 100 woman years) made it 1.34 times and in the late perimenopause (incidence 14.5 per 100 woman years) made it 1.52 times more likely for women to develop monthly or more frequent incontinence. In contrast, women in postmenopause (incidence 8.2 per 100 woman years) were approximately one half as likely to develop this degree of incontinence. This pattern of association across the menopausal transition was similar for stress and urge incontinence. However, menopausal stage was not associated with developing more frequent incontinence (leaking several times per week or more). Worsening anxiety symptoms, a high baseline body mass index, weight gain, and new onset diabetes were associated with developing more frequent incontinence.

CONCLUSION

Menopausal transition stage was associated with developing monthly or more frequent but not weekly or more frequent incontinence, suggesting that only infrequent incontinence symptoms were attributable to the perimenopause. Because modifiable factors such as anxiety, weight gain, and diabetes were associated with developing more frequent incontinence, determining whether healthy life changes and treating medical problems can prevent incontinence is a priority.

LEVEL OF EVIDENCE

II.

Effect of estrogen on bladder nociception in rats

PURPOSE

We assessed the effect of ovariectomy and estrogen replacement on nociceptive responses to bladder distention in a rat model.

MATERIALS AND METHODS

Female Sprague-Dawley rats (Harlan) underwent ovariectomy or sham surgery. Visceromotor responses (abdominal contractions) to bladder distention were determined 3 to 4 weeks later under isoflurane anesthesia. In rat subsets estrogen was chronically replaced with a subcutaneous estrogen pellet vs a placebo pellet or acutely replaced by subcutaneous injection 24 hours before testing. Effects of estrogen withdrawal were examined in another group of rats by implanting a pellet and explanting the pellet 24 hours before testing. Uterine weight was measured to assess the estrogen dose.

RESULTS

Visceromotor responses to bladder distention were significantly less vigorous in ovariectomized rats vs controls. Acute estrogen replacement increased visceromotor responses in these rats but chronic estrogen replacement did not. Sudden chronic estrogen withdrawal resulted in increased visceromotor responses. Uterine weight was consistent with the physiological estrogen dose.

CONCLUSIONS

Estrogen alone was not sufficient to produce increased nociceptive responses but an acute decrease in estrogen resulted in increased visceromotor responses. These data suggest that the pronociceptive effects of estrogen may be due to a mismatch between peripheral vs central and/or genomic vs nongenomic effects of the hormone, which occur during rapidly decreasing estrogen levels.

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.

Influence of estradiol on micturition thresholds in the rat: involvement of the hypogastric nerve

Studies have shown that the severity of bladder hyperreflexia induced by acute bladder inflammation varies with the ovarian cycle. These results suggest that the hyperreflexia is modulated by ovarian hormones. Other studies have suggested that such modulation involves the bladder's sympathetic innervation. These hypotheses were tested by assessing the development of bladder hyperreflexia in urethane-anesthetized rats subjected to different hormonal manipulations with or without bilateral hypogastric neurectomy (HYPX). The groups included sham ovariectomy (sham OVX), ovariectomy (OVX), OVX with estradiol replacement (OVX+E), OVX+HYPX, and OVX+HYPX+E. Assessments were performed using repeated cystometrograms (CMGs) to measure micturition thresholds (MT) before and hourly for 3 h after intravesicular treatment with 50% turpentine oil (or olive oil in an OVX+E control group). In the uninflamed bladder, treatment with estradiol increased MTs in the OVX+E group compared with the OVX group. As expected, bladder inflammation induced bladder hyperreflexia in sham OVX rats (studied in estrus). This hyperreflexia was eliminated by OVX and restored by either estradiol replacement or HYPX. Combining estradiol replacement and HYPX (i.e., OVX+E+HYPX) did not increase the severity of bladder hyperreflexia compared with either manipulation alone. These results indicate that the bladder hyperreflexia that is induced by bladder inflammation requires the presence of estradiol and suggest that this hormonal modulation is exerted via the sympathetic control of the bladder, possibly via an increase of beta-adrenergic inhibitory actions on the detrusor muscle. Similar mechanisms may contribute to bladder disorders in postmenopausal women.