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.

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.

An evidence-based approach to lifestyle interventions in urogynaecology.

Urinary incontinence, urgency, overactive bladder symptoms, cystitis and urinary tract infections are common conditions that collectively trouble over one-third of the female population around and beyond the time of menopause, with a detrimental effect on physical, social and mental wellbeing. Apart from pharmacological and surgical treatments, a long list of lifestyle, behavioural, physical and complementary interventions have been introduced over the years to relieve lower urinary tract symptoms. This review examines the effect on these symptoms of lifestyle factors (such as weight, smoking, dietary components, fluid intake, exercise and bowel habit), complementary therapies (such as herbal remedies, acupuncture and hypnotherapy), behavioural therapies (bladder training and timed and prompted voiding), pelvic floor muscle training and some over-the-counter preparations. The high prevalence of the above conditions in combination with the increasing publicity for and awareness of the subject has contributed to the popularity of the interventions considered in this review. Many of them, however, lack a solid evidence base with regard to their efficacy and few have been subjected to robust randomized trials. It is widely recognized that there is a need for further prospective interventional studies of all lifestyle interventions to evaluate the effects of modifying these factors on lower urinary tract symptoms.

Which procedure for incontinence?

Approximately 16-29% of women will complain of incontinence at the menopause. A multidisciplinary approach to treatment is essential and surgery is usually reserved for women who have failed to improve sufficiently with conservative measures, such as pelvic floor exercises. The Burch colposuspension remains the 'gold standard' procedure for stress urinary incontinence, against which all newer procedures are compared. It is normally carried out under general anaesthesia and requires an abdominal approach, most often by a low transverse incision. Tension-free vaginal tape (TVT) is the most popular procedure at present and has largely replaced colposuspension in many units. However, there are concerns about both its long-term safety and the lack of data on efficacy beyond the first few years. Initial reports of transobturator tape suggest that it may have a similar efficacy to TVT but with a lower rate of serious complications; however, large comparative studies and longterm follow-up data are currently unavailable. Collagen and silicone injected around the urethra can be used in a selected group of patients under local anaesthetic but the success rates are disappointingly low.

A double-blind placebo-controlled trial on the effects of 25 mg estradiol implants on the urge syndrome in postmenopausal women.

The aim of this prospective double-blind randomized placebo-controlled trial was to determine the effect of systemic estrogen on the 'urge syndrome' in postmenopausal women. The trial took place in a tertiary referral urogynecology unit. Postmenopausal women with the 'urge syndrome' were randomly allocated to receive a 25 mg 17beta-estradiol implant or placebo implant. Serum estradiol levels and endometrial thickness were measured on entry to the trial and at 1, 3 and 6 months. The following outcome measures were employed: videocystourethrography, frequency volume chart, visual analogue score of symptoms, and King's Health Care Quality of life Questionnaire. Forty women were included. Subjectively there was a significant improvement in urgency in both groups and urge incontinence in the estradiol group, but no significant differences between the groups. Objectively no significant differences were demonstrated between the groups. Nine women in the estradiol group had vaginal bleeding, and 5 had a hysterectomy during or after the study. Despite using numerous outcome measures to examine its effect, 25 mg estradiol implants did not produce a greater improvement in the 'urge syndrome' than placebo and had a high complication rate.