Urinary incontinence is an important issue for peri- and postmenopausal women. In a recent study of U.S. women, half of the participants between the ages of 50 and 90 experienced urine leakage every month.1 And the severity of incontinence was found to increase with age. Prompt and effective treatment of urinary incontinence symptoms is possible but requires an open conversation in which the nurse takes into account the patient's treatment concerns and preferences. It also requires knowledge of the available treatments. It may be helpful, then, to review current research on the effectiveness of estrogen in treating urinary symptoms and to provide guidance on appropriate nursing interventions.
AGE-RELATED CHANGES
As estrogen production decreases and ultimately ceases, the female genitourinary tract undergoes significant changes. The vaginal mucosa flattens, thins, and pales while vaginal pH rises, increasing the likelihood of bacterial growth. Women may report symptoms caused by urogenital atrophy, including atrophic vaginitis (symptoms include vaginal bleeding, dryness, and burning) and urinary symptoms (such as urinary tract infection and urinary frequency, urgency, and incontinence).2 Until recently, oral hormone replacement therapy (HRT) was thought to be effective for reducing stress incontinence.3
HRT FOR URINARY SYMPTOMS
New evidence. Recent study findings do not support the use of oral HRT to treat urinary incontinence. A landmark longitudinal study examining the effects of HRT in 27,347 women between 50 to 79 years of age found that continent women taking conjugated equine estrogen (CEE) alone or estrogen with progestin (medroxyprogesterone acetate [MPA]) developed urinary incontinence at a statistically significantly higher rate than did continent women taking a placebo.4 In addition, incontinence worsened in women taking CEE alone or CEE and MPA in combination compared with those taking a placebo. The authors concluded that the oral estrogen formulations used in the study increased the risk of urinary incontinence and therefore should not be used to treat it; however, they acknowledged that further research is needed.
Another study supports this conclusion. Goldstein and colleagues followed 619 postmenopausal women (mean age, 53) who had a hysterectomy and were randomized to one of four treatment groups.5 The researchers found that those taking CEE reported a statistically significantly higher rate of new incontinence than those on a placebo or raloxifene (Evista; doses of either 60 or 150 mg/dL). The reason for the increased risk of new incontinence or worsening of existing incontinence is unknown.
A survey of current recommendations. The North American Menopause Society's position statement on the use of estrogen and progestogen in peri- and postmenopausal women recommends local (transvaginal) estrogen therapy for treating vaginal dryness or atrophic vaginitis.6 But it makes no recommendations on hormone use for urinary symptoms. Recommendations from the American College of Obstetricians and Gynecologists, however, discourage the use of oral HRT for incontinence.7 The role of other factors that may influence urge incontinence-such as age and vascular disease-has not been explored fully.8
Estrogen applied locally has been shown to lower vaginal pH, which may reduce recurrent urinary tract infections.9 In addition, Ballagh found evidence that estrogen applied locally may alleviate urgency; however, no lessening of urge incontinence was identified.10 Rigorous studies are needed to investigate the effects of local estrogen therapy on urinary incontinence and its symptoms.8 Nevertheless, despite a lack of solid evidence, clinicians routinely prescribe transvaginal creams (Premarin, Estrace), tablets (Vagifem), and vaginal rings (Estring) to postmenopausal women with atrophic vaginitis and urinary symptoms.11, 12
EDUCATING PATIENTS
Nurses should inform patients that no evidence currently supports the effectiveness of oral estrogen as a treatment for incontinence. Although often used in clinical practice, little research exists on the effectiveness of topical estrogen as a treatment for urinary incontinence, urgency, or frequency. Explain to patients that postmenopausal changes in the genitourinary tract are normal; urinary urgency, frequency, and incontinence are not. Encourage patients to discuss problems with incontinence-the majority of women do not do so.13 A recent literature review found that fewer than 38% of women with urinary incontinence sought help for their condition, and those who did waited more than a year to do so.14 Many factors that place a woman at risk for becoming incontinent can be modified, including obesity, amount and type of fluid intake, smoking, major depression, and the use of certain medications. A list of drug classes that may cause incontinence is available online through the National Association for Continence at http://www.nafc.org/about_incontinence/faqs/faq1.htm.
Behavioral interventions such as pelvic floor-muscle exercise or bladder retraining can often effectively treat urinary incontinence.15 Lifestyle modifications can also be effective. Such modifications include regulating fluid type and amount, managing bowel function, and performing a quick, intentional pelvic floor muscle contraction to prevent accidental leakage prior to the event that causes the incontinence (for example, a cough, sneeze, or change in body position). (An overview of treatment and management options is presented in Table 1, page 36.) A comprehensive assessment, including discussion of the patient's goals and preferences, must be undertaken before initiating a new treatment plan.
RESOURCES
National Association for Continencehttp://www.nafc.org
National Institute of Diabetes and Digestive and Kidney Diseaseshttp://kidney.niddk.nih.gov/kudiseases/topics/incontinence.asp
Simon Foundation for Continencehttp://www.simonfoundation.org
REFERENCES