Study investigates vaginal estrogen for urinary symptoms of menopause

Contemporary OB/GYN:

Hi, I'm Celeste Krewson with contemporary OB/GYN and I'm here with Dr. Christmas to discuss a study titled, “Menopause hormone therapy and urinary symptoms: a systematic review.” Would you like to introduce yourself?

Monica Christmas, MD:

Hi, I'm Dr. Monica Christmas. I'm an associate professor at the University of Chicago in the Department of Obstetrics and Gynecology. And I'm the director of the menopause program there and the Center for Women's Integrated Health.

Contemporary OB/GYN:

So, can you tell me a bit about the study and your findings?

Christmas:

Yeah, so you know, the funny thing is that the idea to do this study came out of another project that I was working on, it was an international project where we were developing a core outcome set for menopause studies. Prior to the development of this core outcome set, researchers that were developing a new drug or treatment for basal motor symptoms, hot flashes, night sweats, or genital urinary symptoms like urinary urgency, frequency, incontinence, recurrent urinary tract infections um the things that we'll talk about in my study. So, previously, when you were doing it, you could pick whatever outcome measures you wanted. And what would happen is when you had got down to comparing treatments, you really couldn't compare them because each study used a different outcome measure to assess their treatment. Many times, they even used different words to define what they were studying. So, this global project, comma, the core outcomes in menopause, developed a core outcome set, it's a minimum measurement that says that if you are developing a study to look at the treatment efficacy of whatever thing you're looking at, for either vasomotor symptoms or one of these genital urinary symptoms, you need to at least use this minimum outcome set to assess your treatment. So, at any rate now, forwarding to the question, you asked me about my study, we're sitting in this global meeting with a lot of top heads in the menopause world, and there is this really spirited discussion about whether or not these urinary symptoms actually should be part of the genital urinary syndrome of menopause. Historically, it was just vaginal atrophy, vaginal dryness that was related to estrogen deficiency, that dryness could lead to pain with intercourse or bleeding with intercourse. And so, everybody kind of agreed on that. But what was the controversy was whether the urinary symptoms, the urgency, the frequency, and recurrent urinary tract infections; were they really due to estrogen deficiency from menopause? Or could they have just been related to aging? And so, this conversation went on, we couldn't even really get to the topic at hand, which had to do with the core outcome set because the experts in the room didn't all agree that urinary symptoms should be included. And so that's what really prompted me to do this systematic review, I wanted to see whether or not we had proven in the literature, that urinary symptoms did actually have some correlation with menopause. And because many of us are using estrogen, hormone replacement therapy, well, for vaginal atrophy, local vaginal estrogen is the first line treatment. And so, if you're saying that urinary symptoms are part of this genital urinary syndrome of menopause umbrella, then you're also thereby saying that vaginal estrogen or estrogen in general replacement should treat those symptoms. And so that's really what we looked at. We looked at all the randomized control trials that were done up until 2021, when we stopped our literature review. And 1 looked at does hormone therapy actually improve urinary symptoms? And then we also were trying to ascertain, was there some evidence that urinary symptoms were truly related to estrogen deficiency? And what we found was that one, we really couldn't in the literature, even looking at epidemiological studies, really couldn't find anything that truly proved that these urinary symptoms were related to menopause. And one of the big things that we saw is that systemic doses like higher doses of hormone therapy, actually, and many studies like the WHI where there were over 17,000 women enrolled in the study, that actually, systemic dose hormone therapy could cause new onset urinary symptoms, or in people that already had them at baseline could worsen their symptoms. Smaller studies showed the same thing. And then when we looked at all of the studies that assess local low-dose vaginal estrogen, so estrogen cream, estrogen, low dose estrogen ring, a low dose estrogen tablet or suppository, those all showed, actually, that local vaginal estrogen actually helped to improve those symptoms. And you would think, well, well, why is that? I don't have the answer to that. So don't ask me that question next.

Contemporary OB/GYN:

Alright, well, that was gonna be my next question. So instead, what steps can providers take to help women with urinary symptoms receive the treatment they need?

Christmas:

Well, I think one thing is understanding that systemic dose hormone therapy is different than local low-dose estrogen therapy. And so, when we're counseling our patients about why we're going to choose one or the other, I think that's an important nuance. So systemic or higher dose therapy is indicated when you are managing hot flashes and night sweats. It's also indicated for the prevention of osteoporosis. And you should also, unless there's a contraindication, use systemic higher dose hormone therapy, in somebody that goes through premature menopause, someone that goes through menopause earlier than the age of 40. Vaginal estrogen, the local low-dose estrogen, does have a because it's not systemically absorbed and has a different safety profile. And so, if somebody only has is presenting with your genital urinary symptoms, either vaginal dryness that leads to pain with intercourse, or bleeding with intercourse, or those urinary symptoms that I discussed, then you really don't need to use systemic dose hormone therapy with them, you only need to use local low dose estrogen. And that's an important nuance because if there's a potential that it could cause or worsen their symptoms, you really don't want to put them on it. If somebody though, has both, let's say you got hot flashes and night sweats, and you've got urinary symptoms, or sorry, vaginal-related symptoms to menopause, then they're probably they're just putting them on a low dose, local vaginal estrogen therapy is not going to help their hot flashes and night sweats. So, for those patients, you do need to probably have them on a systemic dose of hormone therapy, and there are some higher-dose estrogen rings. And so there's some thought that if you use one of the higher dose estrogen rings, it gets placed in the vagina, it stays in the vagina for 90 days, the person takes it out, and then throws it away and puts another one in that because it's actually being absorbed at the level of the vagina, that that actually may help not only alleviate their hot flashes and night sweats but also may help with those genital urinary symptoms as well. If somebody has any type of apprehension, or just doesn't want to use a vaginal estrogen ring, those people actually may need both. And I do think that's good for providers to know that just because you put them on systemic dose hormone therapy, most of them, the majority will come back and say, oh my gosh, I feel like myself again, these hot flashes and night sweats are so much better, or they're gone completely. But you know, I'm still having pain with intercourse, I still feel dry. And some people will think, oh, well, you're already on this, this higher dose estrogen, like, we can't do anything else, or there must be something else wrong. And indeed, actually, what's probably happening is that systemic dose isn't really treating the vaginal symptoms, and you have to give them both. So those people may need a systemic dose hormone therapy as well as a local low dose option to help with those vaginal symptoms.

Contemporary OB/GYN:

That's really interesting. So, what impact do you think this study will have in the future?

Christmas:

Well, I hope that the impact is that it leads to more research and understanding around not just general urinary symptoms related to menopause, but menopause in general. There really has been a paucity of research for menopause, and most of that goes around hormone therapy. And then I think this calls out that we really don't have a great understanding of what symptoms truly are related to estrogen deficiency after menopause, versus those that are related to maybe aging because menopause is inextricably tied to the aging process. And sometimes it's really hard to differentiate that and many times we are attributing a whole host of add things to menopause. And when we do that, it's kind of buying, you know, also saying that hormone therapy may help those things. And as I discussed, there's really only 4 indications for use of hormone therapy. So having a better understanding of truly what symptoms are related to menopause. Are there any preventive things that people can do before they get to the menopause transition to hasten the effect right? And are there other things if it truly is related to menopause? Are there other things we need to be looking at in terms of treatment options?