Estrogen therapy influence on periurethral vessels in postmenopausal incontinent women using Dopplervelocimetry analysis

doi:10.1016/j.maturitas.2008.07.015

Maturitas

Volume 61, Issue 3, 20 November 2008, Pages 243-247

https://doi.org/10.1016/j.maturitas.2008.07.015 Get rights and content

Abstract

Lack of estrogen affects the urinary tract mainly by diminishing vascular, muscular and epithelial trophism, resulting in negative effects on continence in postmenopausal women. Therefore, the use of estrogens in these patients may revert these alterations and lead to an expressive improvement of the urinary symptoms.

Objective

Study the effect of topical estrogen therapy (conjugated equine estrogens, estriol or promestriene) in periurethral vessels detected by Dopplervelocimetric analysis using, as parameters: the number of vessels, resistance and pulsatility indexes, as well as the minimum diastolic value.

Methods

Forty-one postmenopausal women with stress urinary incontinence were randomized into three groups according to different types of topical estrogen received during 3 months. Group 1 received conjugated equine estrogens, group 2 received estriol and group 3 received promestriene. Periurethral Dopplervelocimetry analysis was done before estrogen administration and during treatment in all groups.

Results

We observed an increase in the number of the periurethral vessels in group 1 and group 2, being higher in group 1 than in group 2. The pulsatility index remained unchanged in all three groups. The resistance index at the periurethral vessels reduced only at the conjugated estrogen group (group 1). In this same group we noticed an increase in the mean minimal diastolic value, meaning a better periurethral vascularization.

Conclusion

Topical conjugated equine estrogens and estriol were effective in increasing the number of periurethral vessels in postmenopausal women with urinary stress incontinence, with the conjugated equine estrogens being the most effective intervention studied.

Introduction

Several factors are involved in the etiology of the stress urinary incontinence. For urinary continence to occur, it is necessary that the urethral pressure maintain itself greater than the bladder pressure [1]. The periurethral vessels are responsible for one third of the urethral pressure. Striated muscle is responsible for another third, and the remaining is attributed to the smooth muscle and to the conjunctive periurethral tissue [2]. All these structures are influenced by hormonal action, which is explained by the common embryological origin between the low urinary tract and the genital tract [3]. Therefore, the benefits of estrogen therapy in postmenopausal women are observed at all the components of the urogenital tract, specially at the vascular portion [4], [5].

A considerable amount of women prefer not to use systemic estrogen therapy. Ten to 25% of the patients using systemic estrogen therapy persist with urogenital atrophic symptoms [6]. For these cases, the topical administration of estrogen, in the form of cream or vaginal ring or soft capsules should be the choice, and an excellent option for the treatment of atrophic vaginitis. Many topical treatments have been tried in the management of genital atrophy with estriol, promestriene and conjugated estrogens [7]. These substances also may improve urinary symptoms since it has been shown that estrogen receptors are present at the urethra with a similar concentration to the estrogen receptors seen at the vagina [6], [7].

Hilton and Stanton demonstrated a reduction in the severity of the symptoms of stress urinary incontinence and urinary urgency after administration of 1.25 mg of conjugated estrogens (vaginal cream) during 4 weeks [7].

Pharmacokinetic studies have demonstrated that after administration of a vaginal cream with conjugated estrogens, a fast absorption occurs. A substantial increase of estradiol and estrone at the plasma, and a reduction of gonadotrophins also occur [8], [9].

Estriol is one of the final metabolites of estradiol and has been used for the treatment of urogenital atrophy in postmenopausal women. It promotes the trophism of the vaginal and urethral epithelium, restores the microflora and physiological pH of the vagina, diminishing the incidence of urogenital complaints [10].

Some authors state that endometrial proliferation does not occur with the use of estriol, because of its shorter time of nuclear retention when compared with estradiol [11], [12]. Iosif, in 1992, observed that 75% of postmenopausal women with urinary incontinence improved their urinary loss after vaginal administration of a soft capsule with 0.5 mg of estriol. He also noticed a discrete proliferation at the endometrium in 7 of the 48 evaluated patients [11].

Another substance applied in the vagina is promestriene, a synthetic topical estrogen with an efficient action on the vaginal atrophy; making no difference on the plasmatic levels of gonadotrophins or estradiol, and having no stimulation at the endometrium [12], [13]. Arvis et al. using 10 mg of promestriene vaginally during 3 months in 31 postmenopausal patients with urinary complains has demonstrated a 63.6% total cure of the symptoms of stress urinary incontinence, polaciuria and of urinary urgency [14].

A non-invasive study of the effect of steroid hormones at the vascularization of the female low urinary tract technique, was done by Dopplervelocimetric parameters at the periurethral vessels. [15], [16], [17], [18], [19]. The parameters used with this technique were: number of vessels, resistance and pulsatility indexes as well as the minimum diastolic value.

The objective of this study was to analyze the effect on the periurethral vessels in postmenopausal women with stress urinary incontinence, using three different types of vaginal estrogen creams.

Section snippets

Patients and methods

51 postmenopausal women with clinical history and urodynamic study demonstrating stress urinary incontinence without intrinsic sphincter deficiency were selected. We did not include women with sphincter deficiency because this type of incontinence had a bad response regarding clinical treatment such as hormonal therapy or physiotherapy.

We did not include patients with anemia, uncontrolled diabetes, morbid obesity, hiperactive bladder, genital prolapse stadium III or IV of ICS classification,

Statistical analysis

To compare groups before hormonal therapy regarding age, menopause time, parity, body index mass and Dopplervelocimetric parameters we used a non-parametric test Kruskal-Wallis and when necessary complemented by multiple comparison test. The Friedman non-parametric test was used for the analysis of our results (α < 0.05) between time zero and during hormone therapy. The multiple comparison test and chi-square tests associated with Cochran’s theorem were also used when needed. To evaluate the

Results

The three groups were similar in age, body mass index, postmenopausal time and Doppler parameters before estrogen replacement (T0—number of periurethral vessels, pulsatility and resistance indexes and minimal diastolic values).

We observed a significant increase in the number of periurethral vessels in group 1 during the second and third months of treatment (Table 1 and Fig. 1). In group 2, this increase occurred during the first and third months of hormone treatment (Table 2 and Fig. 3). In

Discussion

Hipoestrogenism leads to atrophic modifications in the genitourinary tract and may predispose to urinary incontinence. The use of estrogen therapy for postmenopausal women brings innumerable urogenital benefits, for example an increase in numbers of periurethral vessels and thickness of mucosa-submucosa layers, leading to a better urethral coaptation [5], [17], [18], [19], [20], [21], [22]. Estrogens also increase the flow of submucosa vascular plexus probably by increasing the number of

Conclusion

In synthesis, our results demonstrate that the vaginal conjugated equine estrogens and estriol are more efficient in bettering the periurethral vascularization compared to local promestriene. Therefore, we believe that postmenopausal women with urinary stress incontinence without sphincter deficit, receiving local hormonal treatment with conjugated estrogens or estriol will have more benefit with urinary continence compared to promestriene. Moreover, we demonstrated that Dopplervelocimetry at

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Estrogen therapy influence on periurethral vessels in postmenopausal incontinent women using Dopplervelocimetry analysis

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Statistical analysis

Results

Discussion

Conclusion

Urology

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Maturitas

Obstet Gynecol

Maturitas

Am J Obstet Gynecol

Int J Gynecol Obstet

Obstet Gynecol

Factors maintaining the intraurethral pressure in women

Inv Urol

Urethral vascular pulsations

Proc Int Cont Soc

Effects of estrogen–progestogen hormonal replacement therapy on periurethral and bladder vessels

Int Urogynecol J

Recent advances in hormone replacement therapy

Br J Hosp Med