Hormone therapy in pelvic floor disorders

Sessions were presented by Dr Tomi Mikkola, Helsinki University, and Professor Tommaso Simoncini, University of Pisa.

A woman has an estimated 20% risk of developing SUI (stress urinary incontinence) or POP (Pelvic Organ Prolapse) by the age of 80 (Wu et al, 2014).

The presence of hormone receptors in pelvic floor structures suggest that hormone therapy could regulate its function, infact oestrogen has traditionally been thought to reduce the risk of common pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI). Multiple studies have found improvements in SUI as well as other urinary complaints, such as urgency, frequency etc.

Is it good quality data though?

Cochrane’s 2012 study review, actually found that systemic oestrogen caused worsening of urinary incontinence but local may have beneficial effects. A more recent systemic review of local oestrogens and UI (urinary incontinence) for 4000 women, found that SUI and urgency were improved, however the studies in SUI were low quality and those in urgency only moderate quality. Based on this and the absence of data on oestradiol, a form of HT commonly used in Europe, Dr Mikkola’s team decided to carry out a study to evaluate the effect of hormone therapy (HT) on POP and SUI.

Significant increase in SUI and POP risks

The, as yet unpublished results, suggested that hormone therapy actually increases the risk of both POP and SUI – with oestradiol-only therapy increasing SUI risk by 4 times. This risk of SUI increases with exposure length and if initiated after 55 years of age. POP risk increased by 40% compared to controls, increased with exposure time however starting age is not a factor in this case.

What about local HT?

Dr Mikkola summarised that local vaginal oestradiol use likely has low/no increase in risk for SUI. Another recent study summarised that systemic HT may have minor negative effect on pelvic organ support.

Oestrogen found to have a detrimental effect on collagen in endopelvic fascia, fascia that is so essential in maintaining pelvic support

A six month study was conducted to assess the impact of 2mg oestradiol treatment on pelvic collagen synthesis and degradation. End study vaginal biopsies revealed total collagen content was reduced and the rate of different tyoe of colleagen synthesis was affected, suggesting the decrease in total collagen was replaced by a weaker collagen type. Increase in proteinase may also have an effect on collagen degradation. Study on paraurethral tissue found similar effect.

Patients should be informed

Dr Mikkola suggests his team’s findings should be incorporated into patient information for women considering hormone therapy.

A need for pelvic floor data in menopause

Professor Simacini stated that although we know there is an association between menopause and pelvic floor dysfunction (PFD), we need more data on the potential implications of menopause on PFD and progression of PFD disorders. Structral effects such as menopausal urogenital atrophy should be investigated more, we’re missing data on how oestrogen and androgens particularly influence nerves, muscles and function – this is so important together with fascia structures and collagens to ensure correct pelvic floor function and on organs themselves within the pelvic floor.

Pain and PFD

Myofascial pain, particularly joint pain, is associated with PFD, many patients can benefit from therapies targeting postural and muscular function. Recurrent UTIs seen in older women are associated with urogenital atrophy, the many of these patients develop bladder pain, which is one of the triggers for chronic pelvic pain in the menopause and during ageing, and of course associated with sexual dysfunction. Urinary incontinence can also cause sexual dysfunction; desire and arousal are prevented by pain, fear of leakage and concentration required to keep control. Bladder function changes throughout life, bladder sensitivity and emptying are not just consequences of PFD, in terms of prolapse, they’re also features of ageing of the pelvic nerve system, particularly if women have diabetes or initial CNS impairment.

Holistic treatment

A Urogynaecologist may need to work with a Colorectal Surgeon and Gastroenterologist, as many other non-gynae areas are modified by the menopause. The intestinal microbiome changes, this can impact constipation, frequency and therefore frequency of infections of the vagina and the bladder, this is an area that we have no knowledge on.

How can we improve PFD and, specifically, POP care?

Can we identify women at risk in the delivery room? We need to establish whether risk scoring works.

Pelvic floor training

Pelvic floor muscle training is interesting, certainly will not cause harm, however, specific nurses and physicians will be required for specific pelvic floor exercises - could also encourage general Pilates though. Reduction of straining and aggressively treating obstructive defecation, a very frequent cause of POP, could also be encouraged.

Lifestyle changes and surgery

Body weight increase prevention, smoking cessation, different surgery methods – surgeries are a risk factor for POP. We don’t have big evidence on these points. Hormones and pelvic floor gym activities are good in decreasing symptoms , could reduce women seeking surgery as most women with intermediate prolapse will not seek surgery, depending on symptoms. Possible strategy to make a difference. Weight loss has many positive effects, reduction of SUI, though on POP there is no information. Big studies insufficient in urinary incontinence and POP.

Hysterectomy and constipation

Chronic constipation is an important risk factor, it's not being tested but it is within clinical appreciation that most patients who have very advanced POP have a history of hysterectomy or obstructive defecation, two big risk factors. We need to consider if we can modify hysterectomy surgery (and other gynaecological surgeries) or treat obstruction aggressively as a means of POP prevention.

Urinary microbiota in recurrent UTI patients

More studies should be carried out on the change in urinary bacterial colonisation after menopause to try and treat patients with recurrent UTIs.

Pain needs to be addressed

There's not enough of an appreciation of the link between chronic pelvic pain, VVA and urinary dysfunction, which should be addressed.

Diagnostic ultrasonography and dynamic MRIs

New ultrasound devices allow complex sonography to stage prolapse. Dynamic MRIs are the future, these will assist with studies as will provide additional consistency in the prolapse staging for reliable evidence.

Learning programmes and computer assisted surgery

Difficult to teach physicians and students about pelvic floor dysfunction, often comes down to experience and personal development. New imaging techniques will make a difference to learning programmes. Surgery will follow this advancement with computer-assisted surgery becoming a reality in the next few years, this robotic platform will help understanding and planning for surgery.