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Effect of Hormonal Changes on Voiding in the Elderly Woman

  • Geriatric Bladder Dysfunction (GM Ghoniem, Section Editor)
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Abstract

Hormonal loss after menopause result in changes that occur to the vaginal epithelium, which shares a common embryological origin with the lower urinary tract. These changes due to hypoestrogenism lead to symptoms of urinary frequency, urgency, incontinence, dysuria, and recurrent urinary tract infections. Replacement of estrogen can provide benefits to some of these conditions, but potential complications associated with the use of unopposed estrogen (including cardiovascular and oncogenic) have given clinicians pause for concern before administering it to patients without adequate counseling. This review article will examine the pathophysiology of the urogenital changes that occur after hormonal loss. We will discuss several well-designed trials that answer questions about the relationship between hormone replacement therapy and overactive bladder, stress incontinence, and recurrent urinary tract infections. In light of the controversy over estrogen therapy and patients’ warranted concerns about the risks, we will also discuss newer hormonal agents, their role in treating this condition, as well as how we counsel patients on a reasonable hormone replacement therapy (HRT) regimen.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Portman DJ, Gass ML, Panel VATCC. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Maturitas. 2014;79(3):349–54.

    Article  CAS  PubMed  Google Scholar 

  2. Iosif CS, Bekassy Z. Prevalence of genito-urinary symptoms in the late menopause. Acta Obstet Gynecol Scand. 1984;63(3):257–60.

    Article  CAS  PubMed  Google Scholar 

  3. Ingelman-Sundberg A, Rosén J, Gustafsson SA, Carlström K. Cytosol estrogen receptors in the urogenital tissues in stress-incontinent women. Acta Obstet Gynecol Scand. 1981;60(6):585–6.

    Article  CAS  PubMed  Google Scholar 

  4. Bernstein IT. The pelvic floor muscles: muscle thickness in healthy and urinary-incontinent women measured by perineal ultrasonography with reference to the effect of pelvic floor training. Estrogen receptor studies. Neurourol Urodyn. 1997;16(4):237–75.

    Article  CAS  PubMed  Google Scholar 

  5. Chen GD, Oliver RH, Leung BS, Lin LY, Yeh J. Estrogen receptor alpha and beta expression in the vaginal walls and uterosacral ligaments of premenopausal and postmenopausal women. Fertil Steril. 1999;71(6):1099–102.

    Article  CAS  PubMed  Google Scholar 

  6. Robinson D, Cardozo LD. The role of estrogens in female lower urinary tract dysfunction. Urology. 2003;62(4 Suppl 1):45–51.

    Article  PubMed  Google Scholar 

  7. Hillard T. The postmenopausal bladder. Menopause Int. 2010;16(2):74–80.

    PubMed  Google Scholar 

  8. Liang CC, Lee TH, Chang SD. Effects of sex hormones on cell proliferation and apoptosis in the urinary bladder muscle of ovariectomized rat. Taiwan J Obstet Gynecol. 2013;52(3):335–40.

    Article  PubMed  Google Scholar 

  9. Robinson D, Toozs-Hobson P, Cardozo L. The effect of hormones on the lower urinary tract. Menopause Int. 2013;19(4):155–62.

    PubMed  Google Scholar 

  10. Elliott RA, Castleden CM. Effect of progestogens and oestrogens on the contractile response of rat detrusor muscle to electrical field stimulation. Clin Sci (Lond). 1994;87(3):337–42.

    Article  CAS  Google Scholar 

  11. Davison SL, Bell R, Donath S, Montalto JG, Davis SR. Androgen levels in adult females: changes with age, menopause, and oophorectomy. J Clin Endocrinol Metab. 2005;90(7):3847–53.

    Article  CAS  PubMed  Google Scholar 

  12. Zumoff B, Strain GW, Miller LK, Rosner W. Twenty-four-hour mean plasma testosterone concentration declines with age in normal premenopausal women. J Clin Endocrinol Metab. 1995;80(4):1429–30.

    CAS  PubMed  Google Scholar 

  13. Glaser R, Kalantaridou S, Dimitrakakis C. Testosterone implants in women: pharmacological dosing for a physiologic effect. Maturitas. 2013;74(2):179–84.

    Article  CAS  PubMed  Google Scholar 

  14. Kwon JK, Kim JH, Choi H, et al. Voiding characteristics and related hormonal changes in peri-menopausal and post-menopausal women: a preliminary study. Maturitas. 2014;79(3):311–5. This study examined which hormones contributed to LUTS and sought to determine if changes in hormone levels during the menopausal transition significantly affected LUTS using standardized voiding symptom questionnaires. Their results suggested frequency can potentially worsen in the perimenopausal period, and SUI is more prevalent in the postmenopausal period; serum testosterone levels in women undergoing the menopausal transition negatively correlated with LUTS.

    Article  PubMed  Google Scholar 

  15. Lin WY, Rehfuss A, Whitbeck C, et al. Effect of letrozole on urinary bladder function in the female rabbit. BJU Int. 2007;100(6):1391–5.

    Article  CAS  PubMed  Google Scholar 

  16. Irwin DE, Kopp ZS, Agatep B, Milsom I, Abrams P. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int. 2011;108(7):1132–8.

    Article  PubMed  Google Scholar 

  17. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20(6):327–36.

    CAS  PubMed  Google Scholar 

  18. Fantl JA. The lower urinary tract in women—effect of aging and menopause on continence. Exp Gerontol. 1994;29(3-4):417–22.

    Article  CAS  PubMed  Google Scholar 

  19. Moehrer B, Hextall A, Jackson S. Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev. 2003;2:CD001405.

    PubMed  Google Scholar 

  20. Prentice RL, Chlebowski RT, Stefanick ML, et al. Conjugated equine estrogens and breast cancer risk in the Women’s Health Initiative clinical trial and observational study. American journal of epidemiology. 2008;167(12):1407–15.

    Article  PubMed Central  PubMed  Google Scholar 

  21. Hendrix SL, Cochrane BB, Nygaard IE, et al. Effects of estrogen with and without progestin on urinary incontinence. Jama. 2005;293(8):935–48.

    Article  CAS  PubMed  Google Scholar 

  22. Stothers L. Should hormone replacement therapy be used in postmenopausal women for voiding dysfunction? Can Urol Assoc J. 2009;3(2):150–2.

    PubMed Central  PubMed  Google Scholar 

  23. Northington GM, de Vries HF, Bogner HR. Self-reported estrogen use and newly incident urinary incontinence among postmenopausal community-dwelling women. Menopause. 2012;19(3):290–5.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database Syst Rev. 2012;10:CD001405.

    PubMed  Google Scholar 

  25. Jackson S, James M, Abrams P. The effect of oestradiol on vaginal collagen metabolism in postmenopausal women with genuine stress incontinence. Bjog. 2002;109(3):339–44.

    Article  CAS  PubMed  Google Scholar 

  26. Baglia ML, Gu K, Zhang X, et al. Soy isoflavone intake and bone mineral density in breast cancer survivors. Cancer Causes Control. 2015;26(4):571–80.

    Article  PubMed  Google Scholar 

  27. Okada S, Kojima Y, Hamamoto S, Mizuno K, Sasaki S, Kohri K. Dietary soy isoflavone replacement improves detrusor overactivity of ovariectomized rats with altered connexin-43 expression in the urinary bladder. BJU Int. 2009;103(10):1429–35.

    Article  CAS  PubMed  Google Scholar 

  28. Shenfeld OZ, McCammon KA, Blackmore PF, Ratz PH. Rapid effects of estrogen and progesterone on tone and spontaneous rhythmic contractions of the rabbit bladder. Urol Res. 1999;27(5):386–92.

    Article  CAS  PubMed  Google Scholar 

  29. Fantl JA, Wyman JF, Anderson RL, Matt DW, Bump RC. Postmenopausal urinary incontinence: comparison between non-estrogen-supplemented and estrogen-supplemented women. Obstet Gynecol. 1988;71(6 Pt 1):823–8.

    CAS  PubMed  Google Scholar 

  30. Cayan F, Tek M, Balli E, Oztuna S, Karazindiyanoglu S, Cayan S. The effect of testosterone alone and testosterone + estradiol therapy on bladder functions and smooth muscle/collagen content in surgically menopause induced rats. Maturitas. 2008;60(3-4):248–52. This study investigated the effect of testosterone alone and testosterone + estradiol therapy on bladder function and smooth muscle/collagen content in the surgically induced menopause rat model. It concluded bladder dysfunction is related to estrogen and androgen deficiency, and combination therapy may improve bladder functions and histology much better than estrogen therapy alone.

    Article  CAS  PubMed  Google Scholar 

  31. Kim NN, Min K, Pessina MA, Munarriz R, Goldstein I, Traish AM. Effects of ovariectomy and steroid hormones on vaginal smooth muscle contractility. International journal of impotence research. 2004;16(1):43–50.

    Article  CAS  PubMed  Google Scholar 

  32. Casson PR, Elkind-Hirsch KE, Buster JE, Hornsby PJ, Carson SA, Snabes MC. Effect of postmenopausal estrogen replacement on circulating androgens. Obstet Gynecol. 1997;90(6):995–8.

    Article  CAS  PubMed  Google Scholar 

  33. Nelken RS, Ozel BZ, Leegant AR, Felix JC, Mishell Jr DR. Randomized trial of estradiol vaginal ring versus oral oxybutynin for the treatment of overactive bladder. Menopause. 2011;18(9):962–6.

    Article  PubMed  Google Scholar 

  34. Serati M, Salvatore S, Uccella S, Cardozo L, Bolis P. Is there a synergistic effect of topical oestrogens when administered with antimuscarinics in the treatment of symptomatic detrusor overactivity? Eur Urol. 2009;55(3):713–9.

    Article  CAS  PubMed  Google Scholar 

  35. Yarnell JW, Voyle GJ, Sweetnam PM, Milbank J, Richards CJ, Stephenson TP. Factors associated with urinary incontinence in women. J Epidemiol Community Health. 1982;36(1):58–63.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  36. Mishra GD, Cardozo L, Kuh D. Menopausal transition and the risk of urinary incontinence: results from a British prospective cohort. BJU Int. 2010;106(8):1170–5.

    Article  PubMed Central  PubMed  Google Scholar 

  37. Jackson S, Shepherd A, Brookes S, Abrams P. The effect of oestrogen supplementation on post-menopausal urinary stress incontinence: a double-blind placebo-controlled trial. Br J Obstet Gynaecol. 1999;106(7):711–8.

    Article  CAS  PubMed  Google Scholar 

  38. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. Jama. 2002;288(3):321–33.

    Article  CAS  PubMed  Google Scholar 

  39. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. Jama. 2013;310(13):1353–68. This study was a continuation of the Women’s Health Initiative, with cumulative 13 years follow-up after enrollment. The increased risk of urinary incontinence seen in women on systemic conjugated equine estrogens with or without medroxyprogesterone acetate during the initial WHI persisted at most recent follow-up, reinforcing that systemic hormones should not be used for preventing incontinence among other chronic diseases in postmenopausal women.

    Article  CAS  PubMed  Google Scholar 

  40. Townsend MK, Curhan GC, Resnick NM, Grodstein F. Postmenopausal hormone therapy and incident urinary incontinence in middle-aged women. Am J Obstet Gynecol. 2009;200(1):86. e81-85.

    PubMed Central  PubMed  Google Scholar 

  41. Liapis A, Bakas P, Georgantopoulou C, Creatsas G. The use of oestradiol therapy in postmenopausal women after TVT-O anti-incontinence surgery. Maturitas. 2010;66(1):101–6.

    Article  CAS  PubMed  Google Scholar 

  42. Tinelli A, Malvasi A, D'Anna L, Tinelli R, Perrone A, Tinelli FG. Presurgical promestriene therapy in postmenopausal women with stress urinary incontinence. Gynecol Endocrinol. 2007;23(8):445–50.

    Article  CAS  PubMed  Google Scholar 

  43. Beisland HO, Fossberg E, Moer A, Sander S. Urethral sphincteric insufficiency in postmenopausal females: treatment with phenylpropanolamine and estriol separately and in combination. A urodynamic and clinical evaluation. Urol Int. 1984;39(4):211–6.

    Article  CAS  PubMed  Google Scholar 

  44. Kobata SA, Girão MJ, Baracat EC, et al. Estrogen therapy influence on periurethral vessels in postmenopausal incontinent women using Dopplervelocimetry analysis. Maturitas. 2008;61(3):243–7.

    Article  CAS  PubMed  Google Scholar 

  45. Long CY, Liu CM, Hsu SC, Wu CH, Wang CL, Tsai EM. A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Menopause. 2006;13(5):737–43.

    Article  PubMed  Google Scholar 

  46. Luthje P, Brauner H, Ramos NL, et al. Estrogen supports urothelial defense mechanisms. Sci Transl Med. 2003;5(190):190ra180.

    Google Scholar 

  47. Hannan TJ, Hooton TM, Hultgren SJ. Estrogen and recurrent UTI: what are the facts? Sci Transl Med. 2013;5(190):190fs123.

    Article  Google Scholar 

  48. Eriksen B. A randomized, open, parallel-group study on the preventive effect of an estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in postmenopausal women. Am J Obstet Gynecol. 1999;180(5):1072–9.

    Article  CAS  PubMed  Google Scholar 

  49. Beerepoot MA, Geerlings SE, van Haarst EP, van Charante NM, ter Riet G. Nonantibiotic prophylaxis for recurrent urinary tract infections: a systematic review and meta-analysis of randomized controlled trials. J Urol Dec. 2013;190(6):1981–9.

    Article  CAS  Google Scholar 

  50. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med. 1993;329(11):753–6.

    Article  CAS  PubMed  Google Scholar 

  51. Cardozo L, Lose G, McClish D, Versi E, de Koning GH. A systematic review of estrogens for recurrent urinary tract infections: third report of the hormones and urogenital therapy (HUT) committee. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(1):15–20.

    Article  CAS  PubMed  Google Scholar 

  52. Portman D, Palacios S, Nappi RE, Mueck AO. Ospemifene, a non-oestrogen selective oestrogen receptor modulator for the treatment of vaginal dryness associated with postmenopausal vulvar and vaginal atrophy: a randomised, placebo-controlled, phase III trial. Maturitas. 2014;78(2):91–8.

    Article  CAS  PubMed  Google Scholar 

  53. Nappi RE, Panay N, Bruyniks N, Castelo-Branco C, De Villiers TJ, Simon JA. The clinical relevance of the effect of ospemifene on symptoms of vulvar and vaginal atrophy. Climacteric. 2015;18(2):233–40.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  54. Simon J, Portman D, Mabey RG, Group OS. Long-term safety of ospemifene (52-week extension) in the treatment of vulvar and vaginal atrophy in hysterectomized postmenopausal women. Maturitas. 2014;77(3):274–81.

    Article  PubMed  Google Scholar 

  55. Archer DF, Carr BR, Pinkerton JV, Taylor HS, Constantine GD. Effects of ospemifene on the female reproductive and urinary tracts: translation from preclinical models into clinical evidence. Menopause. 2015;22(7):786–96. This manuscript provides a comprehensive overview of the mechanism of action that ospemifene has on the genitourinary tract in both animal studies and clinical data. This agent appears to have no significant adverse effect on urinary symptoms in a 52-week study, which may offer an alternative use of hormone manipulation without a direct agonist effect.

    Article  PubMed Central  PubMed  Google Scholar 

  56. Goldstein SR, Nanavati N. Adverse events that are associated with the selective estrogen receptor modulator levormeloxifene in an aborted phase III osteoporosis treatment study. Am J Obstet Gynecol. 2002;187(3):521–7.

    Article  CAS  PubMed  Google Scholar 

  57. Waetjen LE, Brown JS, Modelska K, et al. Effect of raloxifene on urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2004;103(2):261–6.

    Article  CAS  PubMed  Google Scholar 

  58. Goldstein SR, Neven P, Cummings S, et al. Postmenopausal Evaluation and Risk Reduction With Lasofoxifene (PEARL) trial: 5-year gynecological outcomes. Menopause. 2011;18(1):17–22.

    Article  PubMed  Google Scholar 

  59. Fishman JR, Flatt MA, Settersten RA. Bioidentical hormones, menopausal women, and the lure of the “natural” in U.S. anti-aging medicine. Soc Sci Med. 2015;132:79–87.

    Article  PubMed  Google Scholar 

  60. Ayton RA, Darling GM, Murkies AL, et al. A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol. 1996;103(4):351–8.

    Article  CAS  PubMed  Google Scholar 

  61. Barentsen R, van de Weijer PH, Schram JH. Continuous low dose estradiol released from a vaginal ring versus estriol vaginal cream for urogenital atrophy. Eur J Obstet Gynecol Reprod Biol. 1997;71(1):73–80.

    Article  CAS  PubMed  Google Scholar 

  62. Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2006;4:CD001500.

    PubMed  Google Scholar 

  63. Shim SH, Lee SJ, Kim SN. Effects of hormone replacement therapy on the rate of recurrence in endometrial cancer survivors: a meta-analysis. Eur J Cancer. 2014;50(9):1628–37.

    Article  CAS  PubMed  Google Scholar 

  64. Vaccaro CM, Mutema GK, Fellner AN, et al. Histologic and cytologic effects of vaginal estrogen in women with pelvic organ prolapse: a randomized controlled trial. Female Pelvic Med Reconstr Surg. 2013;19(1):34–9.

    Article  PubMed  Google Scholar 

  65. Rahn DD, Good MM, Roshanravan SM, et al. Effects of preoperative local estrogen in postmenopausal women with prolapse: a randomized trial. J Clin Endocrinol Metab. 2014;99(10):3728–36.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  66. Rahn DD, Good MM, Roshanravan SM, et al. Effects of preoperative local estrogen in postmenopausal women with prolapse: a randomized trial. The Journal of clinical endocrinology and metabolism. 2014;99(10):3728–36.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

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The authors declare that they have no competing interests.

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Authors and Affiliations

  1. Department of Urology, Detroit Medical Center, 4160 John R. Suite 1017, Detroit, MI, 48201, USA

    Esther Han

  2. Fellow, Female Pelvic Medicine and Reconstructive Surgery, Beaumont Health System, 3535 W. 13 Mile Road, Ste. 438, Royal Oak, MI, 48073, USA

    Priyanka Gupta

  3. Department of Urology, Oakland University William Beaumont School of Medicine, 31157 Woodward Avenue, Royal Oak, MI, 48073, USA

    Jason P. Gilleran

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  1. Esther Han
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  2. Priyanka Gupta
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  3. Jason P. Gilleran
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Correspondence to Jason P. Gilleran.

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This article is part of the Topical Collection on Geriatric Bladder Dysfunction

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Han, E., Gupta, P. & Gilleran, J.P. Effect of Hormonal Changes on Voiding in the Elderly Woman. Curr Bladder Dysfunct Rep 10, 362–369 (2015). https://doi.org/10.1007/s11884-015-0339-y

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