menopau

Menopau:TheJournalofTheNorthAmericanMenopauSociety

Vol.18,No.12,pp.1268Y1269

DOI:10.1097/gme.0b013e318238e157

*2011byTheNorthAmericanMenopauSociety

EDITORIAL

Urineleakage:menopauornormalaging?

BDoctor,Ijustthoughtmyleakingurinewasnor-

malatmyageIisn_titnormal?[Weknowthat

theanswertothisquestionisnotalwayssimple

becauurinarycontinencehasrathercomplexphysiology.

Urinarycontinenceisanabilitytostoreurinewithconve-

ence

requiresacomplexcoordinationofmultiplecomponentsthat

includemusclecontrol(contractionandrelaxation),appropri-

ateconnectivetissuesupport,andcommunicationofstructures

oftheurinarytractachievedthroughinnervationandcentral

yincontinence(UI)isacom-

plaintofinvoluntarylossofurine.1Twoofthemostcommon

UImanifestationsaredescribed:stressurinaryincontinence

(SUI),whichislossofurinethatisassociatedwithanincrea

inintra-abdominalpressureaswithsneezing,coughing,orphys-

icalactivity,andurgeurinaryincontinence(UUI),whichisin-

voluntarylossofurineassociatedwithasudden,compelling

nsationofurgetovoidthatisdifficulttodefer.

Fromobrvationalstudies,weknowthatapproximatelya

quarterofyoungwomen,morethanhalfofmiddle-agedand

postmenopausalwomen,andnearlythreequartersofolder

-

over,70%ofpostmenopausalwomenwithUIrelatetheont

ofthesymptomstotheirfinalmenstrualperiod.2Indeed,

theprevalenceofUIandotherlowerurinarytractsymptoms

(urinaryurgency,frequency,andnocturia)emstosteadily

ore,istheprevalence

ofUIanormalpartofaging?Thereisanongoingdebateon

whetherthemechanismofthisobrvedincreaisrelatedto

aging,hormonaldeficiency,ualmechanismby

whichhormonaldeficiencycouldaffectUIandurinarysymp-

tomsisnotwellunderstood.

ManystudiesaimedtoexploretherelationshipbetweenUI

thisliteraturefocusonunder-

standingurinarysymptomsandurinarycontinenceinthecon-

yyears,systemicestrogen

hormonetherapywasbelievedtoimprovelowerurinarytract

estdata,however,challengethisbe-

2010

Cochranereview3foundthatsystemicuofestrogenalone

(estrogentherapy;syntheticandconjugatedequineestrogens)

canwornanyUIcomparedwithplacebo(RR,1.32;95%

CI,1.17-1.48).Combinationhormoneestrogenandproges-

teronetherapyproducedsimilarresultswhencomparedwith

placebo(RR,1.11;95%CI,1.04-1.18).Furthermore,continent

womenwhoreceivedsystemicestrogenaloneorincombina-

tionwithprogesteroneweremorelikelytoreportthede-

indings,however,wereheavily

weightedbythedatafromtheWomen’sHealthInitiative,4in

otherhand,locallyadministeredvaginalestrogenmayhavea

eCochrane

review3alsofoundevidencethatlocallyudestrogen(creams

ortablets)improveincontinence(RR,0.74;95%CI,0.64-0.86)

reatedwithlocalestrogenwerereporting

onetotwolessvoidsin24hoursandnocturnallyandless

frequencyandurgency.

r

workbyCardozoetal5aimedtoclarifytheroleofestrogenin

overactivebladder(OAB),asyndromethatincludesUUIand

multipleassociatedsymptoms:urinaryurgency,daytimefre-

quency,ametersthatarethoughttobe

importantinOABsyndromewereexplored:diurnalfrequency,

nocturnalfrequency,urgency,incontinenceepisodes,firstn-

sationtovoid,a-analysisin-

cluded11randomizedcontrolledtrials(n=430)exploring

theimpactofvaginalversussystemicestrogenadministration.

Localestrogenadministrationprovidedgreatersymptomatic

icestro-

genswerefoundtoimprovefirstnsationtovoidandreduce

incontinenceepisodescomparedwithplacebo.

-

times,datashowingstatisticalimprovementarederivedfrom

combiningnonstatisticallysignificantdatathatmaynoteasily

translateintoclinicalimprovementandhenceintoclinical

er,mostofthetrialsincludedinthemeta-

analyswerenotdesignedtoinvestigateincontinenceand

rmore,

on-

sistencyofestrogenpreparationsanddosagesaswellasthe

heterogeneityofobjectiveandsubjectivecriteriaofUIim-

provementandcureaddsdifficultytoresultinterpretation.

InthecurrentissueofMenopau,thearticlebyWaetjen

etal6aimstoenhanceourunderstandingoftherelation-

shipbetweenrumhormonelevelsandurinarysymptomsin

ongitudi-

nalanalysisofalargecohortofwomenduringperimeno-

pau,nocorrelationwasfoundbetweenannuallymeasured

rumestradiollevelsanddevelopmentorworningofincon-

tion,noassociationwasfoundbetweenfollicle-

stimulatinghormone,testosterone,ordehydroepiandrosterone

sulfatelevelsandthedevelopmentorworningofinconti-

indingssuggestthatrumconcentrationsof

endogenouslyandphysiologicallyproducedestrogensarenot

1268Menopau,Vol.18,No.12,2011

Copyright©orizedreproductionofthisarticleisprohibited.

sduringthe

menopausaltransition,itisnotthechangesintherumhor-

monelevelsbutratherthechangesintheend-tissueeffectof

hormonesthatmodulateurinarysymptoms.

Theprecimechanismthroughwhichestrogensandper-

hapsotherhormonesaffectcontinenceispoorlyunderstood.

Compromiinurogenitalconnectivetissueisoneofthecom-

monpathogenesofSUIandisthefocusofSUIrearch.7

Dataareconflictingontheeffectsofestrogensonurogenital

enhasalsobeenpropodtoin-

creaurethralresistance,toraithensorythresholdofthe

bladder,toincreaurethralsmoothmuscle>-adrenergicre-

ceptornsitivity,andtopromoteA-3adrenergicreceptorVthe

mediationrelaxationofthedetrusormuscle.8

Sharingacommonembryologicorigin,lowerurinaryand

femalegenitaltractsaresimilarlynsitivetotheeffectsof

-affinityestrogenreceptors(ERs)

andprogesteronereceptorshavebeenfoundintheconnective

tissue,smoothmuscleandneuronaltissueofvagina,urethra,

bladdertrigone,andpelvicfloormusculature.9,10Someinves-

tigatorsdemonstratedthattheurogenitaltissuesofwomen

ith

SUIhadlowerERconcentrationsinpelvicfloortissues(pelvic

floormusclesandconnectivetissue).11Theconcentrationof

anteriorvaginalwallER-Awasfoundtobelowerinpost-

menopausalwomenwithSUI.12Otherinvestigatorspropo

thatgeneticsusceptibilitytoUIdevelopmentmaycontribute

tal13

foundthatandrogenreceptorpolymorphismislinkedtoge-

neticsusceptibilitytoUI.

Theinteractionofurinarycontinence,menopau,and

agingisstillunclear;however,evidencepointstosomeim-

pactofmenopausalhormonaldeficiencyontheprevalence

ofUI,urogenitaltissuesstatus,evels

ofhormonesdonotcorrelatewiththedevelopmentofUI.

Moreover,systemichormone(orestrogen)therapymaybe

ciinteractionof

hormonaldeficiencyandurinarycontinenceisnotwellelu-

ng

isclear,UIinofallitsmanifestationsismultifactorialand

amongotherinfluencesisaffectedbythehypoestrogenic

tmenopausalwomenwithUI,it

isreasonabletoasssforsignsofurogenitalatrophyand

considertopicalestrogen,whereassystemichormonereplace-

ore,isurinaryleakingjust

partofnormalaging?Perhapsindirectly.

Financialdisclosure/conflictsofinterest:Nonereported.

ein,MD

VincentObstetricsandGynecologyService

MassachuttsGeneralHospital

Boston,Massachutts

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Menopau,Vol.18,No.12,20111269

EDITORIAL

Copyright©orizedreproductionofthisarticleisprohibited.