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Home Health Professionals Issues WHI: Incontinence

WHI and Urinary Incontinence

Note from Dr Elizabeth Farrell: While the article below "WHI and Urinary Incontinence: a review" should now be viewed as an archive, the conclusion is still valid. 

Conclusion

Traditionally oestrogen therapy has been used to treat genitourinary symptoms associated with the menopause, including urinary incontinence. The WHI study has shown that urinary incontinence increased in the women on both E+P and E alone compared to the placebo group. There are many risk factors for urinary incontinence that can be modified by lifestyle improvement, a healthy diet and pelvic floor physiotherapy.

Oestrogen therapy is still the most appropriate therapy for atrophic symptoms of genitourinary system. The use of vaginal preparations for these symptoms may be the preferable form of oestrogen.

Content Updated July 15 , 2008

WHI and Urinary and Incontinence: a review

Dr Elizabeth Farrell MBBS, FRANZCOG, FRCOG
Menopause Unit, Southern Health, Clayton and The Jean Hailes Foundation, Clayton.

A further Women's Health Initiative (WHI) study was published in February 2005 which showed an increase in the incidence of urinary incontinence on Hormone Therapy (HT) compared to placebo.1

This trial measured the incidence of urinary incontinence (UI) at one year in women who had no previous history of UI at the beginning of the study and the severity of the UI at one year in women with a history of UI at the commencement of the study.

The conclusions reached were that there was an increase in the incidence of UI in women on both oestrogen and progestin (E+P) and oestrogen alone (E) at one year compared to women receiving placebo. The greatest increase was in the women suffering from stress incontinence (SI), followed by those with mixed incontinence. Urge incontinence was slightly increased in those women on E alone but not in those women on E+P.

The second part of the study showed an increase in frequency of UI and a worsening in the interference with daily activities in those women on HT who had UI at the start of the study.

From a number of epidemiological studies the risk factors for UI have been identified:

  • Increasing age
  • Higher Body Mass Index
  • Hysterectomy
  • Stroke
  • Diabetes
  • COAD
  • Vaginal births
  • Perineal trauma from vaginal delivery
  • Recurrent urinary tract infections
  • Hormone therapy.

In the Melbourne Midlife study women with incontinence were more likely to have a higher body mass index (BMI), gynaecological surgery, three or more children, urinary tract infections and suffered from constipation or diarrhoea.2

in the Health, Aging and Body Composition study, urge incontinence was associated with white race, insulin dependent diabetes, depression, arthritis, oral oestrogen therapy and reduced physical activity. Stress incontinence was associated with high BMI, white race, oral oestrogen therapy, arthritis and chronic obstructive airways disease (COAD).3

In a case control study of women presenting with UI or overactive bladder to gynaecology outpatients, vaginal births were found to increase the risk of both stress incontinence and mixed stress and urge incontinence, but not of urge incontinence or overactive bladder. UI was increased in women with a higher BMI, urinary infection history, hysterectomy or perineal trauma. A history of caesarean section increased the risk of UI compared to nulliparous women.4

In the Study of Osteoporotic Fractures, the risk factors for UI were found to be increasing age, previous hysterectomy, higher BMI, history of stroke, diabetes, COAD, and poor overall physical health. Women who walked faster had a lower risk.5

The participants in the WHI study had the following characteristics at baseline:

Characteristics       
 E+P
E alone
Age > 60 years 60-70% 70%
BMI >25        68-69% 78-79%
Parity>2 82% 81-82%
Menopause >10 years 64% 81%
HT never use    74% 51-52%
Diabetes 5-6% 9.5%
Chronic lung disease 9-10% 12-13%
Stroke 1% 1-1.5% 

The study groups had many of the risk factors considered to increase the incidence of UI, including the oestrogen only group, who had all had a hysterectomy.

The women who had UI at baseline were divided into those with SI, urge incontinence and mixed incontinence, with the women in the oestrogen only group having a greater frequency of leakage in all the types of incontinence, than the women in the E+P group.

SI was experienced in a frequency of more than once a month, but less than once a week by 68% of women in the E+P group and 60% in the E only group. Whereas 62% experienced urge incontinence and 46% experienced mixed incontinence, with a similar frequency more than once a month, but less than once a week in the E+P group, and 55% with urge incontinence and 36% with mixed incontinence in E only group. Most of the women in all groups losing only small amounts, 85% in SI (E+P) to 62% in mixed incontinence (E only). The urinary leakage was more bothersome in the E only groups than the E+P groups.

The results at the end of the one year showed an increase incidence in stress incontinence with a RR 1.87 CI (1.61-2.18) p value.001 in the E+P group and a RR 2.15 CI (1.77-2.62) p value .001 in the E only group compared to the placebo groups. In the mixed incontinence group there was a RR1.49 CI (1.10-2.01) p value 0.01 in E+P group and a RR 1.79 CI (1.26-2.53) p value <0.001 in the E only group in developing incontinence on HT compared to placebo. Urge incontinence was increased in the E only group with a RR 1.32 CI (1.10-1.58) p value 0 .003. The risk of developing UI increased with increasing age and time since menopause.

In those women who experienced UI at baseline, HT increased the risk of worsening UI, greater frequency of leakage and interference with normal daily activities in both the E+P and E alone groups. Interestingly, in the E alone group the women who were older and had normal BMI were at greater risk of more leakage and frequency of UI compared to the placebo group with similar trends in the E+P arm of the study. The effects of HT on increasing and worsening incontinence appeared to continue, but the numbers analysed at three years were small.

This is the first randomized placebo-controlled study to show an increased incidence of UI with both E+P and E alone.1

The Cochrane Review of 28 trials concluded that oestrogen therapy can improve or cure incontinence, but it is more likely with urge incontinence. It appeared that improvement or cure was less likely to occur with combined therapy of E+P. However, the reviewers commented that most of the studies were small samples and short duration, with little standardization of types of therapy used.6

In the Nurses Health Study the risk of UI was increased in the women on HT compared to those women who had never used HT, regardless of the type or route of administration. The types of therapy analysed were oral E alone, transdermal E alone, oral E + P and transdermal E + P. The risk of developing UI appeared to diminish after cessation of therapy.7

In the HERS study the women with pre-existing incontinence who were on E+P therapy had greater severity of symptoms compared to the control group.8

Hormone therapy has traditionally been thought to improve urinary symptoms because of the presence of oestrogen and progesterone receptors within the genitourinary tissues. It has been shown to improve atrophic symptoms of vaginal dryness, atrophic vaginitis, dyspareunia, urgency and recurrent urinary infections. Local vaginal oestrogen therapy may be the more appropriate form of therapy, rather than systemic therapy, as symptoms do not always improve with systemic oestrogen therapy. Progesterone has also been shown to increase urinary symptoms.9

Conclusion

Traditionally oestrogen therapy has been used to treat genitourinary symptoms associated with the menopause, including urinary incontinence. The WHI study has shown that urinary incontinence increased in the women on both E+P and E alone compared to the placebo group. There are many risk factors for urinary incontinence that can be modified by lifestyle improvement, a healthy diet and pelvic floor physiotherapy.

Oestrogen therapy is still the most appropriate therapy for atrophic symptoms of genitourinary system. The use of vaginal preparations for these symptoms may be the preferable form of oestrogen.

References:

1. Hendrix S, Cochrane B, Nygaard I et al. Effects of estrogen with or without progestin on urinary incontinence. JAMA 2005;293:935-948.
2. Sherburn M, Guthrie J, Dudley E et al. Is incontinence associated with menopause? Obstet Gynecol. 2001;98:628-633.
3. Jackson R, Vittinghoff E, Kanaya A et al. Urinary incontinence in elderly women: findings from the Health, Aging, and Body Composition Study. Obstet Gynecol. 2004;104:301-307.
4.  Parazinni F Chiaffarino F, Lavezzari M et al. Risk factors for stress, urge or mixed urinary incontinence in Italy. BJOG. 2003;110:927-933.
5. Brown J, Seeley D, Fong J et al. Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group. Obstet Gynecol. 1996;87:715-721. 
6. Moehrer B, Hextall A, Jackson S. Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev. 2003;(2):CD001405. 
7. Grodstein F, Lifford K, Resnick N, Curhan G. Postmenopausal hormone therapy and risk of developing urinary incontinence. Obstet Gynecol. 2004;103:254-260.
8. Brown J, Grady D, Ouslander J et al. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Heart and Estrogen/Progestin Replacement Study (HERS) Research Group. Obstet Gynecol. 1999;94:66-70.
9. SOGC. The detection and management of vaginal atrophy. Number 145, May 2004. Int J Gynaecol Obstet. 2005;88:222-228.

Content Created June 20, 2005

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