Vaginal estrogen for treatment of urinary symptoms

Vaginal estrogen for treatment of urinary symptoms | Image Credit: © Zerbor - © Zerbor - stock.adobe.com.

According to a recent study published in Menopause, improvements in urinary symptoms and decreased risk of recurrent urinary tract infections (UTI) are accomplished through vaginal estrogen.

Genitourinary syndrome of menopause (GSM) refers to vulvovaginal changes experienced after menopause. Symptoms of GSM include urinary urgency, frequency, dysuria, and recurrent UTIs. Treatment recommendations were updated in 2020 to include vaginal estrogen.

It is important to understand the link between menopause and GSM symptoms, as urinary symptoms are highly prevalent. A link between menopause and urinary symptoms may indicate hormone therapy (HT) could be used for treatment.

To determine the association between menopause and certain urinary symptoms, investigators conducted a systematic review. Symptoms evaluated included dysuria, urgency and frequency, recurrent UTIs, and urinary incontinence.

Studies reviewed included randomized control trials (RCTs) with perimenopausal and postmenopausal women, evaluating urinary symptoms as a primary or secondary outcome. RCTs were written in English and had at least 1 arm of estrogen therapy.

Animal trials, pilot studies secondary analyses, pharmacokinetic studies, cancer studies, position papers, observational studies, and conference abstracts were excluded. Databases searched included Pubmed, Scopus, and the Cochrane Central Register of Controlled Trials. Searches lasted until October 2020.

Search terms were related to menopause, urinary symptoms, and UTIs. Five authors reviewed articles, with data extracted including country of origin, publication date, number of participants, setting, duration, follow-up, mean age of participants, inclusion of race and ethnicity data, inclusion and exclusion criteria, design, outcomes, and main findings.

The Jadad scoring system was used to rate RCTs on their methodological quality. Criteria used to score RCTs included the trial being randomized, using an appropriate randomization method, being blinded, using an appropriate blinding method, and accounting for all randomized participants.

There were 30 RCTs included in the analysis, published from 1978 to 2021 and including data from 17 countries. Only RCTs evaluating the impact of HT on urinary symptoms were included. Based on the Jadad scoring system, 13 of the 30 trials were of medium to high quality.

Statistically significant improvements from oral estrogen were only recorded in a single RCT from 1978, with no other trials indicating improvements from systemic HT. A large RCT known as the Women’s Health Initiative found increased stress incontinence from estrogen only and combined oral HT.

Urinary symptoms were also not improved through subcutaneous estrogen or transdermal estrogen. Data comparing oral estrogen and vaginal estrogen, raloxifene, transdermal estrogen, and oral isoflavone was inconsistent, making it difficult to draw a conclusion.

When evaluating the effects of vaginal estrogen formulations, most RCTs reviewed found statistically significant improvements in urinary symptoms such as dysuria, urinary frequency, stress and urge incontinence, and recurrent UTI reductions.

Overall, there was no conclusive data on the association between menopause and urinary symptoms. However, vaginal estrogen proved effective at treating urinary symptoms and recurrent UTI. Investigators recommended postmenopausal women with urinary symptoms consider vaginal estrogen for treatment.

Reference

Christmas MM, Iyler S, Daisy C, Maristany S, Letko J, Hickey M. Menopause hormone therapy and urinary symptoms: a systematic review. Menopause. 2023;30(6):672-685. doi:10.1097/GME.0000000000002187