Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment and blinding and incomplete outcome data).
Local oestrogen treatment is recommended as second-line treatment for post-menopausal women with urinary incontinence.
The recommendation is weak because of low certainty of evidence. Local oestrogen is a cheap and harmless treatment for urinary incontinence.
A Cochrane review [Abstract] 1 included 34 studies with a total of 19 676 women. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. The combined result of 6 trials of systemic administration (of oral systemic oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result was heavily weighted by a subgroup of women from the Hendrix trial in which all of the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen were combined also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).
Oestrogens used locally (for example vaginal creams or pessaries) improved incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.
Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.
Women were more likely to have an improvement in incontinence after pelvic floor muscle training than with local oestrogen therapy (RR 2.30, 95% CI 1.50 to 3.52; 1 trial).
A randomised trial 3 investigated the effects of the combination of pelvic floor rehabilitation and intravaginal estriol (IE) on SUI treatment in postmenopausal women.62 women with SUI were randomized to PFMT, ES and biofeedback (Group 1) or the same treatment plus 1 mg IE (Group 2) for 6 months. Patients were evaluated with medical history, pelvic examination, urodynamics, 24-hour pad test. Urinary incontinence was evaluated using the International Consultation on Incontinence questionnaire on urinary incontinence short form and quality of life using the Incontinence Impact Questionnaire-Short Form.Mean urine leakage at the 24-hour pad test dropped from 42.3 ± 20.2 g/die to 31.5 ± 14.2 g/die in Group 1 and from 48.3 ± 19.8 g/die to 22.3 ± 10.1 g/die in Group 2. Symptoms scores and incontinence status were statistically significant better in Group 2 when compared to Group 1.
A systematic review 2 assessed vaginal estrogen and its alternatives for women with genitourinary syndrome of menopause (eg, vaginal dryness, dyspareunia, dysuria, urgency, frequency, recurrent urinary tract infection (UTI), Compared with placebo, vaginal estrogens improved dryness, dyspareunia, urinary urgency, frequency, and stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). Urinary tract infection rates decreased. The various estrogen preparations had similar efficacy and safety; serum estradiol levels remained within postmenopausal norms for all except high-dose conjugated equine estrogen cream. Comparing vaginal estrogen with nonhormonal moisturizers, patients with two or more symptoms of vulvovaginal atrophy were substantially more improved using vaginal estrogens, but those with one or minor complaints had similar symptom resolution with either estrogen or nonhormonal moisturizer.
A systematic review 4 included 53 studies. Compared with placebo, all vaginal estrogens demonstrated superiority in objective endpoints and subjective endpoints of genitourinary syndrome. Some trials demonstrated superiority versus placebo in urogenital symptoms. No significant difference was observed between various dosages and dosage forms of vaginal estrogen products. Estrogen showed superiority over vaginal lubricants and moisturizers for the improvement of objective clinical endpoints of vulvovaginal atrophy but not for subjective endpoints.
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