Estrogen treatment for incontinence in frail older women.

Abstract

To the Editor: The role of estrogen in the treatment of urinary incontinence in older women remains unclear. Meta-analyses and one recent clinical trial have failed to demonstrate consistent benefits for symptoms.1-3 We have completed a small placebo-controlled trial of oral estradiol (0.625 mg) combined with progesterone (2.5 mg) in 32 incontinent nursing home residents and have found minimal effects on vaginal and urethral epithelium, or on incontinence severity, even after 6 months of treatment.4 Because regular administration of topical estrogen cream is often difficult in frail older women, even in institutional settings, we conducted a small open-label trial of a vaginal ring that releases estrogen slowly for 3 months (Estring; Pharmacia & Upjohn). Nine consecutive ambulatory older women referred for evaluation of urinary incontinence, who provided informed consent, were enrolled in the study, and five completed the 3-month protocol. The mean age of the five who completed the trial was 83 (range 77 to 94), and all had symptoms and clinical findings consistent with either urge or mixed urge-stress incontinence. Of the four who did not complete the trial, one had dysplastic cells on a screening Pap smear, one could not retain the ring in her vagina because of prolapse, and two withdrew (one because her symptoms improved with behavioral therapy which she had already begun, and the other because she did not believe her symptoms would improve). None of the patients had any discomfort or side effects from the ring. The effects of the ring on the vaginal epithelium were dramatic and occurred within 1 month of ring insertion (Figure 1). The effects on urethral epithelial maturation were almost identical. Vaginal pH fell from 6.4 at baseline to 4.2 by 1 month. Blood estradiol levels remained essentially unchanged (baseline 6.6 ± 4.2 vs 6.6 ± 2.5 at 3 months). None of the patients had major improvement in their symptoms, and all requested additional treatment after the 3-month protocol. . Effects of estrogen-releasing ring on the vaginal epithelium. In contrast to orally administered estrogen, the vaginal ring appears to have prominent and rapid effects on the vaginal epithelium and pH, even among frail older women who have been hypoestrogenic for many years. Results in the five patients we studied suggest that the estrogen ring may be a safe and comfortable method of administering estrogen without concern for systemic effects. However, our experience with these patients, previous research,1-4 and practice guidelines5 suggest that estrogen alone does not result in marked improvement in symptoms of incontinence in the vast majority of older women. It may be a useful adjunct to behavioral or pharmacologic treatment, and topical cream has been shown to prevent recurrent urinary tract infections (UTI) in postmenopausal women.6 We believe that clinicians should consider the use of the estrogen ring for frail older women with symptoms or signs of atrophic vaginitis as an alternative to cream and in addition to oral estrogen being used primarily for other purposes. Future research should determine if this method of delivery of local vaginal estrogen is a useful adjunct to other interventions for incontinence, and whether it prevents recurrent UTI, a major cause of morbidity and health care expenditure in the frail older population.