Menopau:The Journal of The North American Menopau Society
英国初中留学申请Vol.18,No.12,pp.1268Y1269
obama speech in shanghaiDOI:10.1097/gme.0b013e318238e157
*2011by The North American Menopau Society
E DITORIAL
Urine leakage:menopau or normal aging?
B D octor,I just thought my leaking urine was nor-口信
mal at my age I isn_t it normal?[We know that
maskchinatime for miraclethe answer to this question is not always simple becau urinary continence has rather complex physiology. Urinary continence is an ability to store urine with conve-nient and socially acceptable voluntary emptying.Continence requires a complex coordination of multiple components that include muscle control(contraction and relaxation),appropri-ate connective tissue support,and communication o
f structures of the urinary tract achieved through innervation and central nervous system oversight.Urinary incontinence(UI)is a com-plaint of involuntary loss of urine.1Two of the most common UI manifestations are described:stress urinary incontinence (SUI),which is loss of urine that is associated with an increa in intra-abdominal pressure as with sneezing,coughing,or phys-ical activity,and urge urinary incontinence(UUI),which is in-voluntary loss of urine associated with a sudden,compelling nsation of urge to void that is difficult to defer.
From obrvational studies,we know that approximately a quarter of young women,more than half of middle-aged and postmenopausal women,and nearly three quarters of older women in nursing homes experience some degree of UI.More-over,70%of postmenopausal women with UI relate the ont of the symptoms to their final menstrual period.2Indeed, the prevalence of UI and other lower urinary tract symptoms (urinary urgency,frequency,and nocturia)ems to steadily increa starting with menopau.Therefore,is the prevalence of UI a normal part of aging?There is an ongoing debate on whether the mechanism of this obrved increa is related to aging,hormonal deficiency,or both.The actual mechanism by which hormonal deficiency could affect UI and urinary symp-toms is not well understood.
Many studies aimed to explore the relationship between UI and menopausal state.Most of this literat
ure focus on under-standing urinary symptoms and urinary continence in the con-text of hormone therapy.For many years,systemic estrogen hormone therapy was believed to improve lower urinary tract symptoms and UI.The latest data,however,challenge this be-lief and suggest that an opposite trend may exist.The2010 Cochrane review3found that systemic u of estrogen alone (estrogen therapy;synthetic and conjugated equine estrogens) can worn any UI compared with placebo(RR,1.32;95% CI,1.17-1.48).Combination hormone estrogen and proges-terone therapy produced similar results when compared with placebo(RR,1.11;95%CI,1.04-1.18).Furthermore,continent women who received systemic estrogen alone or in combina-tion with progesterone were more likely to report the de-velopment of new UI.The findings,however,were heavily weighted by the data from the Women’s Health Initiative,4in which only conjugated equine estrogens were studied.On the other hand,locally administered vaginal estrogen may have a different affect on urogenital symptoms.The same Cochrane review3also found evidence that locally ud estrogen(creams or tablets)improve incontinence(RR,0.74;95%CI,0.64-0.86) symptoms.Women treated with local estrogen were reporting one to two less voids in24hours and nocturnally and less frequency and urgency.
The Cochrane review did not parate UI by type.Earlier work by Cardozo et al5aimed to clarify the r
ole of estrogen in overactive bladder(OAB),a syndrome that includes UUI and multiple associated symptoms:urinary urgency,daytime fre-quency,and nocturia.Six parameters that are thought to be important in OAB syndrome were explored:diurnal frequency, nocturnal frequency,urgency,incontinence episodes,first n-sation to void,and bladder capacity.The meta-analysis in-cluded11randomized controlled trials(n=430)exploring the impact of vaginal versus systemic estrogen administration. Local estrogen administration provided greater symptomatic relief in all the parameters of OAB syndrome.Systemic estro-gens were found to improve first nsation to void and reduce incontinence episodes compared with placebo.
The meta-analys could still create confusion.Some-times,data showing statistical improvement are derived from combining nonstatistically significant data that may not easily translate into clinical improvement and hence into clinical practice.Moreover,most of the trials included in the meta-analys were not designed to investigate incontinence and were thus powered to asss a different outcome.Furthermore, all meta-analys are subject to publication bias.The incon-sistency of estrogen preparations and dosages as well as the heterogeneity of objective and subjective criteria of UI im-provement and cure adds difficulty to result interpretation.
In the current issue of Menopau,the article by Waetjen et al6aims to enhance our understanding of
the relation-ship between rum hormone levels and urinary symptoms in women during the menopausal transition.In the longitudi-nal analysis of a large cohort of women during perimeno-pau,no correlation was found between annually measured rum estradiol levels and development or worning of incon-tinence.In addition,no association was found between follicle-stimulating hormone,testosterone,or dehydroepiandrosterone sulfate levels and the development or worning of inconti-nence.The findings suggest that rum concentrations of endogenously and physiologically produced estrogens are not
1268Menopau,Vol.18,No.12,2011
responsible for maintaining continence.Perhaps during the menopausal transition,it is not the changes in the rum hor-mone levels but rather the changes in the end-tissue effect of hormones that modulate urinary symptoms.
The preci mechanism through which estrogens and per-haps other hormones affect continence is poorly understood. Compromi in urogenital connective tissue is one of the com-mon pathogenes of SUI and is the focus of SUI rearch.7 Data are conflicting on the effects of estrogens on urogenital tissue composition.Estrogen has also been propod to in-crea urethral re
sistance,to rai the nsory threshold of the bladder,to increa urethral smooth muscle>-adrenergic re-ceptor nsitivity,and to promote A-3adrenergic receptor V the mediation relaxation of the detrusor muscle.8
Sharing a common embryologic origin,lower urinary and female genital tracts are similarly nsitive to the effects of female x steroids.High-affinity estrogen receptors(ERs) and progesterone receptors have been found in the connective tissue,smooth muscle and neuronal tissue of vagina,urethra, bladder trigone,and pelvic floor musculature.9,10Some inves-tigators demonstrated that the urogenital tissues of women with UI have an altered concentration of ERs.Women with SUI had lower ER concentrations in pelvic floor tissues(pelvic floor muscles and connective tissue).11The concentration of anterior vaginal wall ER-A was found to be lower in post-menopausal women with SUI.12Other investigators propo that genetic susceptibility to UI development may contribute to the interaction between x steroids and UI.Cornu et al13 found that androgen receptor polymorphism is linked to ge-netic susceptibility to UI.
The interaction of urinary continence,menopau,and aging is still unclear;however,evidence points to some im-pact of menopausal hormonal deficiency on the prevalence of UI,urogenital tissues status,and function.Serum levels of hormones do not correlate with the development of UI. Moreover,
systemic hormone(or estrogen)therapy may be detrimental to urinary continence.The preci interaction of hormonal deficiency and urinary continence is not well elu-cidated and remains an important area of rearch.One thing is clear,UI in of all its manifestations is multifactorial and among other influences is affected by the hypoestrogenic state of menopau.For postmenopausal women with UI,it is reasonable to asss for signs of urogenital atrophy and consider topical estrogen,whereas systemic hormone replace-ment would not be advisable.Therefore,is urinary leaking just part of normal aging?Perhaps indirectly.
Financial disclosure/conflicts of interest:None reported.
李阳口语宝典
Milena M.Weinstein,MD
Vincent Obstetrics and Gynecology Service
Massachutts General Hospital
Boston,Massachutts
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实习生英文
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