Changes in paraurethral connective tissue at menopause are counteracted by estrogen

Should hormone replacement therapy (any route of administration) be considered in all postmenopausal women with lower urinary tract symptoms? Report from the ICI-RS 2023

AIMS

This International Consultation on Incontinence-Research Society report aims to summarize the evidence and uncertainties regarding the use of hormone replacement therapy by any route in the management of lower urinary tract symptoms (LUTS) including recurrent urinary tract infections (rUTI), with a review of special considerations for the elderly. Research question proposals to further this field have been highlighted.

METHODS

An overview of the existing evidence, guidelines, and consensus regarding the use of topical or systemic estrogens in the management of LUTS.

RESULTS

There are currently evidence and recommendations to offer topical estrogens to postmenopausal women with overactive bladder symptoms as well as postmenopausal women with rUTIs. Systemic estrogens however have been shown in a meta-analysis to have a negative effect on LUTS and, therefore are not currently recommended.

CONCLUSIONS

Although available evidence and recommendations exist for the use of topical estrogens, few women are commenced on these in primary care. There remain large gaps still within our knowledge of the use of estrogens within the management of LUTS, particularly on when it should be commenced, the length of time treatment should be continued for, and barriers to prescribing.

Perinatal mesenchymal stromal cells of the human decidua restore continence in rats with stress urinary incontinence induced by simulated birth trauma and regulate senescence of fibroblasts from women with stress urinary incontinence

Stress urinary incontinence (SUI) is a condition that causes the involuntary loss of urine when making small efforts, which seriously affects daily life of people who suffer from it. Women are more affected by this form of incontinence than men, since parity is the main risk factor. Weakening of the pelvic floor tissues is the cause of SUI, although a complete understanding of the cellular and molecular mechanisms of the pathology is still lacking. Reconstructive surgery to strengthen tissue in SUI patients is often associated with complications and/or is ineffective. Mesenchymal stromal cells from the maternal side of the placenta, i.e. the decidua, are proposed here as a therapeutic alternative based on the regenerative potential of mesenchymal cells. The animal model of SUI due to vaginal distention simulating labor has been used, and decidual mesenchymal stromal cell (DMSC) transplantation was effective in preventing a drop in pressure at the leak point in treated animals. Histological analysis of the urethras from DMSC-treated animals after VD showed recovery of the muscle fiber integrity, low or no extracellular matrix (ECM) infiltration and larger elastic fibers near the external urethral sphincter, compared to control animals. Cells isolated from the suburethral connective tissue of SUI patients were characterized as myofibroblasts, based on the expression of several specific genes and proteins, and were shown to achieve premature replicative senescence. Co-culture of SUI myofibroblasts with DMSC via transwell revealed a paracrine interaction between the cells through signals that mediated DMSC migration, SUI myofibroblast proliferation, and modulation of the proinflammatory and ECM-degrading milieu that is characteristic of senescence. In conclusion, DMSC could be an alternative therapeutic option for SUI by counteracting the effects of senescence in damaged pelvic tissue.

Vaginal collagen I and III changes after carbon dioxide laser application in postmenopausal women with the genitourinary syndrome: a pilot study

OBJECTIVE

The aim of the study was to evaluate the clinical response and collagen remodeling in the vaginal wall after three sessions of carbon dioxide (CO₂) laser application.

METHODS

Fourteen postmenopausal women with vulvovaginal atrophy, aged 45-65 years and sexually active, were evaluated with clinical questionnaires, gynecological examinations and histological techniques before and after 20 weeks of treatment (ClinicalTrials.gov NCT03939078). Treatment consisted of 3-monthly sessions of the CO₂ laser. Clinical questionnaires included the Vaginal Health Index, the Female Sexual Function Index and the International Consultation on Incontinence Questionnaires Short Form. Biopsies were taken from the lateral vaginal wall at week 0 (left wall) and week 20 (right wall). Tissue samples were stained with hematoxylin and eosin, Periodic Acid-Schiff, Picrosirius Red Stain and Orcein dyes. Immunohistochemical study was used to quantify collagens I and III in the samples.

RESULTS

The mean age was 54.4 ± 4.5 years, and the average time of amenorrhea was 7.6 ± 5.1 years. The Female Sexual Function Index and the Vaginal Health Index Score values increased while the International Consultation on Incontinence Questionnaire Short Form score decreased after the programmed treatment. There was no significant change in vaginal pH. Histological studies showed increases in the total and superficial epithelial cell layers, and type III collagen fibers (from 10.86 ± 7.66 to 16.87 ± 3.96, p < 0.05), and immunohistochemical studies confirmed the significant increase in collagen III.

CONCLUSION

Histological findings revealed epithelial atrophy reversal and collagen remodeling of the vaginal wall. Immunohistochemical analysis showed an increase in collagen type III fibers.

Risk factors for vaginal mesh erosion after sacrocolpopexy in Korean women

Objective

Although sacrocolpopexy (SCP) can provide durable apical support, the use of mesh may give rise to various complications, including vaginal mesh erosion. The aim of this study was to identify the risk factors for vaginal mesh erosion after SCP in Korean women.

Methods

This retrospective cohort study included 363 women who underwent SCP with type 1 polypropylene mesh. They were evaluated at 1, 4, and 12 months after surgery and then annually thereafter with respect to anatomy and complications. Univariate and multivariate analyses using the Cox proportional hazard model were performed to identify the risk factors for mesh erosion.

Results

During the median 2-year follow-up period, vaginal mesh erosion was found in 29 women (8.0%). Among them, 19 (65.5%) required surgical correction. Estrogenic status was the only independent risk factor for mesh erosion. The risk for mesh erosion was 4.5 times higher in premenopausal women than in menopausal women not on estrogen replacement therapy (ERT) (95% confidence intervals [CI] 1.9–10.9, p<0.01). Menopausal women on ERT also had an increased risk, with a statistically marginal significance (hazard ratio 2.5, 95% CI 0.9–6.6; p = 0.07).

Conclusions

Premenopausal or menopausal women on ERT are at high risk for mesh erosion after SCP with type 1 polypropylene mesh, and two-thirds of mesh erosion cases require reoperation. This information should be incorporated into patient counseling and treatment decisions.

Effect of vaginal or systemic estrogen on dynamics of collagen assembly in the rat vaginal wall

The objective of this study was to compare the effects of systemic and local estrogen treatment on collagen assembly and biomechanical properties of the vaginal wall. Ovariectomized nulliparous rats were treated with estradiol or conjugated equine estrogens (CEEs) either systemically, vaginal CEE, or vaginal placebo cream for 4 wk. Low-dose local CEE treatment resulted in increased vaginal epithelial thickness and significant vaginal growth without uterine hyperplasia. Furthermore, vaginal wall distensibility increased without compromise of maximal force at failure. Systemic estradiol resulted in modest increases in collagen type I with no change in collagen type III mRNA. Low-dose vaginal treatment, however, resulted in dramatic increases in both collagen subtypes whereas moderate and high dose local therapies were less effective. Consistent with the mRNA results, low-dose vaginal estrogen resulted in increased total and cross-linked collagen content. The inverse relationship between vaginal dose and collagen expression may be explained in part by progressive downregulation of estrogen receptor-alpha mRNA with increasing estrogen dose. We conclude that, in this menopausal rat model, local estrogen treatment increased total and cross-linked collagen content and markedly stimulated collagen mRNA expression in an inverse dose-effect relationship. High-dose vaginal estrogen resulted in downregulation of estrogen receptor-alpha and loss of estrogen-induced increases in vaginal collagen. These results may have important clinical implications regarding the use of local vaginal estrogen therapy and its role as an adjunctive treatment in women with loss of vaginal support.

Relationship between dietary phytoestrogens and development of urinary incontinence in midlife women

OBJECTIVE

Because exogenous estrogen treatment has been associated with a higher risk of urinary incontinence, our objective was to evaluate the longitudinal relationships of dietary phytoestrogen intakes (isoflavones, coumestans, and lignans) and the development of incontinence in midlife women transitioning through menopause.

METHODS

The Study of Women's Health Across the Nation (SWAN) Phytoestrogen Study was developed within SWAN, a community-based, multisite, multiracial/ethnic, prospective cohort study. SWAN interviewers administered a food consumption assessment at baseline and on follow-up visits 5 and 9. The SWAN Phytoestrogen Study created a phytonutrient database that allowed estimation of the usual daily intakes of four isoflavones, four lignans, and coumestrol. On an annual self-administered questionnaire, participants reported on the frequency and type of incontinence. We used discrete proportional hazards models to evaluate whether the estimated daily intake of each phytoestrogen class on the visit previous to the first report of incontinence was associated with the development of monthly or more incontinence versus remaining continent.

RESULTS

We found no association or patterns of association between developing any, stress, or urge incontinence and the reported daily dietary intake of isoflavones, coumestrol, and lignans on the visit previous to the onset of incontinence.

CONCLUSIONS

The results of this longitudinal study provide important information to better understand estrogenlike substances in the continence mechanism of midlife women. Our study shows that neither high nor low dietary intakes of isoflavones, coumestrol, and lignans prevent stress or urge incontinence. Future studies should evaluate whether serum levels of phytoestrogens or their metabolites impact incontinence symptoms.

Effect of menopause on women's periodontium

Steroid sex hormones have a significant effect on different organ systems. As far as gingiva is concerned, they can influence the cellular proliferation, differentiation and growth of keratinocytes and fibroblasts. Estrogen is mainly responsible for alterations in blood vessels and progesterone stimulates the production of inflammatory mediators. In addition, some micro-organisms found in the human mouth synthesize enzymes needed for steroid synthesis and catabolism. In women, during puberty, ovulation, pregnancy, and menopause, there is an increase in the production of sex steroid hormones which results in increased gingival inflammation, characterized by gingival enlargement, increased gingival bleeding, and cervicular fluid flow and microbial changes.

The soy isoflavone genistein inhibits the reduction in Achilles tendon collagen content induced by ovariectomy in rats

The objective of this study was to evaluate the effects of genistein and moderate intensity exercise on Achilles tendon collagen and cross-linking in intact and ovariectomized (OVX) female Sprague-Dawley rats. Rats were separated into eight groups (n = 9/group): intact or OVX, treadmill exercised or sedentary, genistein-treated (300 mg/kg/day) or vehicle. After 6 weeks, tendons were assayed for the collagen-specific amino acid hydroxyproline and hydroxylyslpyridinoline (HP). Collagen content was not influenced by exercise (P = 0.40) but was lower (P < 0.001) in OVX-vehicle rats compared with intact vehicle rats (OVX: 894 ± 35 μg collagen/mg dry weight; intact: 1185 ± 72 μg collagen/mg dry weight). In contrast, collagen content in OVX rats treated with genistein was greater (P = 0.010, 1198 ± 121 μg collagen/mg dry weight) when compared with untreated rats and was not different from intact rats (P = 0.89). HP content was lower in OVX genistein-treated rats when compared with intact genistein-treated rats, but only within the sedentary animals (P = 0.05, intact-treated: 232 ± 39 mmol/mol collagen; OVX-treated: 144 ± 21 mmol/mol collagen). Our findings suggest that ovariectomy leads to a reduction in tendon collagen, which is prevented by genistein. HP content, however, may not have increased in proportion to the addition of collagen. Genistein may be useful for improving tendon collagen content in conditions of estrogen deficiency.

The effect of age, sex, and physical activity on entheseal morphology in a contemporary Italian skeletal collection

Entheseal changes are traditionally included in a large array of skeletal features commonly referred to as "skeletal markers of activity." However, medical studies and recent anthropological analyses of identified skeletal series suggest a complex combination of physiological and biomechanical factors underlying the variability of such "markers." The aim of this study is to examine the relationship between age, sex, physical activity, and entheseal variability. To this end, 23 postcranial entheses are examined in a large (N = 484) Italian contemporary skeletal series using standardized scoring methods. The sample comprises subjects of known age, sex and, mostly, occupation. Results show a strong relationship between age and entheseal changes. Differences between sexes are also highlighted, while the effects of physical activity appear moderate. Altogether, our study indicates that entheseal morphology primarily reflects the age of an individual, while correlation with lifetime activity remains ambiguous.

The integral system

The Integral System is a total care management system based on the Integral Theory which states 'prolapse and symptoms of urinary stress, urge, abnormal bowel & bladder emptying, and some forms of pelvic pain, mainly arise, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue'.

NORMAL FUNCTION

The organs are suspended by ligaments against which muscles contract to open or close the their outlet tubes, urethra and anus. These ligaments fall naturally into a three-zone zone classification, anterior, middle, and posterior.

DYSFUNCTION

Damaged ligaments weaken the force of muscle contraction, causing prolapse and abnormal bladder and bowel symptoms.

DIAGNOSIS

A pictorial diagnostic algorithm relates specific symptoms to damaged ligaments in each zone.

TREATMENT

In mild cases, new pelvic floor muscle exercises based on a squatting principle strengthen the natural closure muscles and their ligamentous insertions, thereby improving the symptoms predicted by the Theory. With more severe cases, polypropylene tapes applied through "keyhole" incision using special instruments reinforce the damaged ligaments, restoring structure and function. Problems that can be potentially addressed by application of the Integral SystemUrinary stress incontinenceUrinary urge incontinenceAbnormal bladder emptyingFacal incontinence and "obstructed evacuation" ("constipation")Pelvic pain, and some types of vulvodynia and interstitial cystitisOrgan prolapse.

CONCLUSIONS

Organ prolapse and symptoms are related, and both are mainly caused by laxity in the four main suspensory ligaments and perineal body. Restoration of ligament/fascial length and tension is required to restore anatomy and function.

Effect of the gonadal status and the gender on glycosaminoglycans profile in the lower urinary tract of dogs

Glycosaminoglycans (GAGs) form a functional component of connective tissues that affect the structural and functional integrity of the lower urinary tract (LUT). The specific GAGs of physiological relevance are both nonsulfated (hyaluronan) and sulfated GAGs (chondroitin sulphate [CS], dermatan sulphate [DS], keratan sulphate [KS], and heparan sulphate [HS]). As GAG composition in the LUT is hormonally regulated, we postulated that gonadectomy-induced endocrine imbalance alters the profile of GAGs in the canine LUT. Four regions of the LUT (body and neck of the bladder as well as the proximal and distal urethra) from 20 clinically healthy dogs (5 intact males, 5 intact anoestrus females, 4 castrated males, and 6 spayed females) were collected, wax-embedded and sectioned. Alcian blue staining at critical electrolyte concentrations was performed on the sections to determine total GAGs, hyaluronan, total sulfated GAGs, combined components of CS and DS, as well as KS and HS. The amount of staining was evaluated in 3 tissue layers, i.e., epithelium, subepithelial stroma and muscle within a region. Overall, hyaluronan (67.1%) was the predominant GAG in the LUT. Among sulfated GAGs, a combined component of KS and HS was found to be 61.8% and 38.2% for CS and DS. Gonadal status significantly affected GAG profiles in the LUT (P < 0.01). All GAG components were lower (P < 0.05) in body of the bladder of gonadectomized dogs. Total sulfated GAGs and a combined component of KS and HS were lower (P < 0.05) in all 4 regions of gonadectomized dogs. Except for a combined component of CS and DS, decreases in all GAGs were found more consistently in the muscle compared to other tissue layers. Differences between genders became obvious only when considered along with the effect of gonadal status. In gonadectomized dogs, changes in GAG components in the LUT were more consistent in females compared to males; this may partly explain different levels of risk in the development of urinary incontinence between genders. Quantitative differences in GAG profiles found between intact and gonadectomized dogs indicate a potential role of gonadectomy-induced endocrine imbalance in modifying GAG composition in the canine LUT. Profound alteration in the pattern of GAGs in gonadectomized dogs may compromise structural and functional integrity of the LUT and is possibly involved in the underlying mechanism of urinary incontinence post neutering.

The influence of sex steroid hormones on gingiva of women

Steroid sex hormones have a significant effect on different organ systems. As far as gingiva are concerned, they can influence the cellular proliferation, differentiation and growth of keratinocytes and fibroblasts. Estrogen is mainly responsible for alterations in blood vessels and progesterone stimulates the production of inflammatory mediators. In addition, some micro-organisms found in the human mouth synthesize enzymes needed for steroid synthesis and catabolism. In women, during puberty, ovulation and pregnancy, there is an increase in the production of sex steroid hormones which results in increased gingival inflammation, characterized by gingival enlargement, increased gingival bleeding and crevicular fluid flow and microbial changes.

Oral contraceptive use and incident urinary incontinence in premenopausal women

PURPOSE

Recent data in postmenopausal women indicate that current and past use of exogenous hormones is related to urinary incontinence risk. Little is known about exogenous hormones and risk of urinary incontinence in younger women. We investigated the association between oral contraceptive pills and incident urinary incontinence in premenopausal women enrolled in the Nurses' Health Study II.

MATERIALS AND METHODS

Participants reported use of oral contraceptive pills from 1989 to 2001. Among 21,864 premenopausal women 37 to 54 years old reporting no urinary incontinence in 2001 we identified 749 with incident urinary incontinence at least weekly between 2001 and 2003. Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression.

RESULTS

Women who had ever used oral contraceptive pills had a statistically significant 27% (95% CI 1-59) increased odds of experiencing urinary incontinence at least weekly compared with those who never used oral contraceptive pills. In women with 10 or more years of use the odds ratio increased to 1.48 (95% CI 1.13-1.95). Ever using oral contraceptive pills was specifically associated with urgency urinary incontinence (OR 2.48, 95% CI 1.07-5.76) rather than stress urinary incontinence (OR 1.04, 95% CI 0.78-1.40). Although we had limited information on urinary tract infection, control for urinary tract infection did not alter these findings.

CONCLUSIONS

Use of oral contraceptive pills may be associated with a modest increase in the odds of urinary incontinence among premenopausal women. However, this is one of the first reports of such an association and, thus, further research is needed to confirm our findings and investigate possible mechanisms.

Postmenopausal hormone therapy and incident urinary incontinence in middle-aged women

OBJECTIVE

The objective of the study was to examine the association of hormone therapy with incident urinary incontinence (UI) in postmenopausal women aged 37-54 years in the Nurses' Health Study II.

STUDY DESIGN

Participants reported use of hormone therapy, including hormone type, on biennial questionnaires from 1989 to 2001. Among 7341 postmenopausal women reporting no UI in 2001, we identified 1026 women who developed UI at least monthly between 2001 and 2003. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Women currently using hormone therapy had 1.39-fold (95% CI, 1.16-1.67) increased odds of incident UI, compared with women who never used hormone therapy. ORs were similar in current users of oral estrogen alone (OR, 1.35, 95% CI, 1.03-1.78) and oral estrogen with progestin (OR, 1.37, 95% CI, 1.13-1.67).

CONCLUSION

These findings suggest an increased risk of UI associated with use of postmenopausal hormone therapy in younger postmenopausal women.

Frequency of de novo urgency in 463 women who had undergone the tension-free vaginal tape (TVT) procedure for genuine stress urinary incontinence—A long-term follow-up

BACKGROUND

To determine risk factors for the appearance of de novo urgency symptoms, and subsequent accompanying problems, after the tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence.

METHOD

A structured preoperative analysis of the incontinence symptoms was made. A mailed questionnaire was distributed to 970 women that underwent the TVT procedure between 1995 and 2001. Average follow-up was 5.2 years (range 2-8 years). The questionnaire included specific questions on current urinary symptoms and incontinence. The disease-specific quality of life instruments IIQ-7 and UDI-6 were used to compare women with, and those without de novo urgency.

RESULTS

Seven hundred and sixty women (78.3%) responded and 463 of those were identified as genuine stress incontinence preoperatively. De novo urgency occurred in 67 (14.5%) of the women. The frequency was similar irrespective of duration since the TVT procedure. The women that reported de novo urgency symptoms were compared with those without symptoms. Risk factors for occurrence of de novo urgency symptoms were older age (64.7 years versus 60.9 years; p=0.01), parity (2.6 versus 2.3; p=0.05), history of cesarean section (9.5% versus 2.5%; odds ratio 5.4), and history of recurrent urinary infections (29.7% versus 18.8%; odds ratio 1.6, but non-significant. De novo urgency had a severe impact on quality of life, as compared to the remaining study population.

CONCLUSION

Old age, parity and history of cesarean section were risk factors for de novo urgency after TVT surgery. Postoperative de novo urgency symptoms are as bothersome for the patient as the preoperative stress urinary incontinence.

The effect of ultralow-dose transdermal estradiol on urinary incontinence in postmenopausal women

OBJECTIVE

To estimate the effect of 2 years of treatment with ultralow-dose transdermal estradiol (E2) on incontinence in postmenopausal women.

METHODS

Ultra Low Dose Transdermal estRogen Assessment (ULTRA) was a multicenter, randomized, double-blinded, placebo-controlled trial of unopposed ultralow-dose (0.014 mg/d) transdermal E2 for prevention of osteoporosis in 417 postmenopausal women aged 60 to 80 years. Frequency of incontinence episodes was assessed at baseline and after 4 months and 2 years of treatment using a self-reported questionnaire. We used an intention-to-treat analysis to compare change in incontinence frequency, improved (decreased 2 or more episodes per week), unchanged (increased or decreased no more than 1 episode per week), or worsened (increased 2 or more episodes per week) between the E2 and placebo groups among women with and without at least weekly incontinence at baseline.

RESULTS

At baseline, the prevalence of at least weekly incontinence was similar between E2 and placebo groups (43%). After 2 years, there was no difference between groups in the proportions of women with incontinence at baseline whose incontinence improved, worsened, or was unchanged. The odds ratio for worsening incontinence in the E2 compared with placebo group was 1.35 (95% confidence interval 0.75-2.42. In women without incontinence at baseline, the odds of developing at least weekly incontinence after 2 years in the E2 compared with placebo group was not significant (odds ratio 1.2, 95% confidence interval 0.7-2.2).

CONCLUSION

Two years of treatment with unopposed ultralow-dose transdermal E2 did not substantially change the frequency of incontinence symptoms or alter the risk of developing at least weekly incontinence.

LEVEL OF EVIDENCE

I.

Microarray analysis of differentially expressed genes in vaginal tissues from women with stress urinary incontinence compared with asymptomatic women

BACKGROUND

The pathophysiology of pelvic floor dysfunction resulting in stress urinary incontinence (SUI) in women is complex. Evidence suggests that there is also a genetic predisposition towards SUI. We sought to identify differentially expressed genes involved in extracellular matrix (ECM) metabolism in vaginal tissues from women with SUI in the secretory phase of menses compared with asymptomatic women.

METHODS

Tissue samples were taken from the periurethral vaginal wall of five pairs of premenopausal, age-matched SUI and continent women and subjected to microarray analysis using the GeneChip Human Genome U133 oligonucleotide chip set.

RESULTS

Extensive statistical analyses generated a list of 79 differentially expressed genes. Elafin, keratin 16, collagen type XVII and plakophilin 1 were consistently identified as up-regulated ECM genes. Elafin, a serine protease inhibitor involved in the elastin degradation pathway and wound healing, was expressed in pelvic fibroblasts and confirmed by Western blot, quantitative competitive PCR and immunofluorescence cell staining.

CONCLUSIONS

Genes involved in elastin metabolism were differentially expressed in vaginal tissue from women with SUI, suggesting that elastin remodelling may be important in the molecular aetiology of SUI.

Estrogen increases collagen I and III mRNA expression in the pelvic support tissues of the rhesus macaque

OBJECTIVE

Our aim was to study the effect of estradiol and raloxifene on collagen synthesis, by measuring the expression collagen I and III mRNA.

STUDY DESIGN

Nineteen nulliparous young adult rhesus macaques underwent oophorectomy and were treated for 5 months with estradiol alone, raloxifene, or no hormone. Tissue samples were acquired from the lateral vaginal wall, and included the paravaginal attachment and levator ani muscle. Expression of mRNA for collagen I and III was measured by in situ hybridization.

RESULTS

Estradiol increased mRNA for collagen I and III compared with no hormone and raloxifene treatment (ANOVA, P < .05). Collagen mRNA was localized to fibroblasts in the vaginal connective tissue and the connective tissue investments of striated muscle. Collagen mRNA was not expressed in epithelial, smooth, and striated muscle cells.

CONCLUSION

Estrogen, but not raloxifene, increases collagen gene transcription and indicates stimulation of collagen synthesis in pelvic floor connective tissues.

Impact of menopause on collagen subtypes in the arcus tendineous fasciae pelvis

OBJECTIVE

The arcus tendineous fasciae pelvis (ATFP) provides support to the anterior vagina. The objective of this study was to determine the impact of menopause on the structural components of the ATFP.

STUDY DESIGN

Biopsy specimens of the ATFP were obtained from 10 premenopausal, 5 postmenopausal, and 12 postmenopausal women on hormone therapy. Scanning confocal microscopy of fluorescent micrographs was used to define the amount of collagen subtypes, smooth muscle, and elastin. Collagen fiber orientation was determined by scanning electron microscopy.

RESULTS

The ATFP is comprised primarily of parallel bundles of type III collagen fibers (84%), an intermediate amount of elastin (13%), and very little smooth muscle. The ratio of collagen I/(III+V) was decreased in postmenopausal not on hormones relative to premenopausal women (P=.04) due to a 75% decrease in collagen I (P=.046). The decrease in collagen I and change in collagen ratios was not present in women on hormone therapy. Comparison of the amounts of elastin and smooth muscle showed no difference in the ATFP of premenopausal and postmenopausal women.

CONCLUSION

Menopause in the absence of hormone therapy is associated with a decrease in quantity of collagen I in the ATFP resulting in a decrease in the ratio of collagen I/(III+V). This may compromise the tensile strength and an increase susceptibility to anterior vaginal wall prolapse.

Sleep and menopause

Many midlife women obtain inadequate sleep, and sleep problems are common during the menopause transition. This article reviews the research literature on sleep and sleep disorders during menopause. Few studies have included subjective and objective measures of sleep quality or studied women during different menopause stages. Potential mechanisms associated with the emergence of insomnia and sleep-disordered breathing during menopause are discussed along with effects of estrogen and progesterone on sleep. It is argued that sleep quality is an important determinant of health status and quality of life for women during and beyond menopause.

Analysis of type I collagen in the parametrium of women with and without uterine prolapse, according to hormonal status

The content and quality of type I collagen in the parametrium of women with and without uterine prolapse was evaluated. Forty-four consecutive patients were selected and divided into two groups: A, 21 women without uterine prolapse, and B, 23 with uterine prolapse. Patients in group A had uterine leiomyoma and were submitted to abdominal hysterectomy; in those from group B, vaginal hysterectomy was performed for correction of the uterine prolapse. During surgery, fragments of the parametrium were removed and processed for immunohistochemical analysis using polyclonal antibodies for type I collagen. A system of computerized digital imaging analysis was used for the quantification of collagen fibers. There was no difference between collagen content in patients either with or without prolapse, nor between pre- and postmenopausal women with prolapse. A modification of the quality of the collagen fiber was observed, it being longer and more compact in the group without uterine prolapse. In contrast, in the group with prolapse, the fibers were shorter and thinner and areas with large spaces between fibers were found at several points of the parametrium. The conclusion was that patients with uterine prolapse have the same type I collagen content as those without, but the quality of the fiber is modified. The hormonal status also did not affect collagen content.

Short-term urogenital effects of raloxifene, tamoxifen, and estrogen

OBJECTIVE

The purpose of this study was to assess the urogenital effects of raloxifene, tamoxifen, conjugated equine estrogen, and placebo in healthy postmenopausal women.

STUDY DESIGN

This randomized, double-blind, placebo-controlled study compared the urogenital effects of 0.625 mg of conjugated equine estrogen (n = 15 women), 20 mg of tamoxifen (n = 14 women), 60 mg of raloxifene, (n = 15 women), and placebo (n = 13 women). Evaluations at baseline and evaluations after 20 weeks receiving the drug included a pelvic examination with cytologic evaluation of vagina and urethra, pelvic organ prolapse quantitation, and urethral axis deflection by cotton swab test (only in patients with incontinence [33%]).

RESULTS

Conjugated equine estrogen increased the maturation value of both urethral and vaginal cytologic condition (P =.002, P =.032, respectively). There was a decrease in vaginal maturation value in the raloxifene group (not significant). Two of 8 women in the conjugated equine estrogen group showed evidence of worsening prolapse by pelvic organ prolapse quantitation; the condition of 2 of 8 women improved. In the raloxifene, tamoxifen, and placebo groups 8 of 12 women, 4 of 13 women, and 2 of 11 women had worsening in prolapse scores, respectively, whereas none of the women had improvement. Increased cotton swab deflection was found in 3 of 5 women in the raloxifene group, in 5 of 8 women in the tamoxifen group, in 0 of 4 women in the placebo group, and in 0 of 2 women in the conjugated equine estrogen group. Seventy-five percent of the patients who received raloxifene and 60% of the patients who received tamoxifen had increases in prolapse by any measure (ie, pelvic organ prolapse quantitation or cotton swab or clinical assessment) compared with 18% of the patients in the placebo group and 22% of the patients in the conjugated equine estrogen group (P =.015), although symptoms did not differ among groups.

CONCLUSION

Neither raloxifene nor tamoxifen improve cytohormonal effects in the vagina or urethra, whereas conjugated equine estrogen does. Raloxifene and tamoxifen appear to show worsening prolapse compared with conjugated equine estrogen and placebo. The clinical relevance of these effects is unknown and requires investigation.

Menstrual phase-dependent gene expression differences in periurethral vaginal tissue from women with stress incontinence

OBJECTIVE

The mechanical stability of the genitourinary tract is dependent on intact collagen fibers that support the bladder neck, urethra, and pelvic organs. We hypothesize that genetic differences in collagen metabolism may contribute to stress urinary incontinence. Because sex hormones have substantial influence on the female lower urinary tract throughout adult life, we investigated the gene expression of vaginal tissue of women with stress incontinence compared with women with no stress incontinence in the proliferative phase of the menstrual cycle.

STUDY DESIGN

Quantitative competitive polymerase chain reaction was used to verify that the gene expressions were similar between periurethral vaginal tissue and pelvic ligamentous tissue. Labeled complementary RNA was obtained from periurethral vaginal tissue in five pairs of age- and menstrual phase-matched, premenopausal women with and without stress urinary incontinence. The vaginal tissues were then hybridized on HuGeneFL arrays that contained probes representing 6800 full-length human genes. The Student t test and Mann-Whitney ranking were used independently to select candidates with probability values <.05. Hierarchical clustering analysis was performed on the selected candidates to assess the ability of these genes to discriminate between normal and affected individuals.

RESULTS

Tissue inhibitor of metalloproteinases-1 and estrogen receptor-alpha messenger RNA expressions were found to be similar between uterosacral ligament and periurethral vaginal tissue in six participants. Of the 90 candidate genes that were identified, 62 genes were up-regulated and 28 were down-regulated in the stress urinary incontinence group. Genes that were involved in extracellular matrix activity in the up-regulated group include transforming growth factor-beta3, laminin, and collagen type VI. Down-regulated genes that may participate in collagen metabolism include laminin-related protein, collagen XVII, serine/threonine protein kinase, type II interleukin-1 receptor, and platelet-derived growth factor-associated protein.

CONCLUSION

In this preliminary study, we identified differential gene expressions that may contribute to extracellular matrix remodeling in pelvic tissue from women with stress urinary incontinence in the proliferative phase versus continent control subjects. The alteration in expression of these candidate genes suggests that they should be targets for further investigation.

Implications of abdominal straining in women with lower urinary tract symptoms

OBJECTIVES

To explore the urodynamic significance of abdominal straining during voiding in female subjects with lower urinary tract symptoms.

METHODS

We retrospectively reviewed a urodynamic database to identify the 180 patients who met the inclusion criteria for this study. None had a history of pelvic surgery, neuropathy, diabetes mellitus, or subjective complaints of voiding difficulty (poor stream, straining to void, hesitancy, or incomplete emptying). None had distortion or compression of the urethra or urodynamic findings of genuine stress incontinence, overactive detrusor, or hypersensitive bladder. All had undergone the pressure-flow study as part of a full urodynamic study to investigate the voiding mechanism. Of the 180 subjects, 100 women were premenopausal and 80 were postmenopausal. One half of the patients in each group had abdominal straining during voiding; the other half did not. Abdominal straining was defined as an increase in abdominal pressure of at least 10 cm H2O greater than baseline, regardless of duration and patterns. Differences in demographics, anatomy, and urodynamic study findings in those with and without abdominal straining were compared in each group.

RESULTS

In premenopausal women, the intravesical opening pressure differed significantly between those with and without abdominal straining (P = 0.011); in postmenopausal women, the significant urodynamic difference was the time to peak flow and minimal urethral resistance (P = 0.017 and 0.023, respectively). Menopause did not affect the voiding patterns.

CONCLUSIONS

Although the clinical manifestation is devoid of voiding difficulty, straining at voiding in female subjects with lower urinary tract symptoms is significantly associated with the urodynamic parameters signifying urethral obstruction, and is a compressive effect in premenopausal women and a constrictive effect in postmenopausal women.

Is diminished pubocervical fascia collagen content a risk factor for failure of surgical management of genuine stress urinary incontinence in women?

OBJECTIVE

The assessment of relationship between pubocervical collagen content and clinical results of surgical treatment of genuine stress urinary incontinence (GSUI) in women.

METHODS

Twenty-four women treated for genuine stress urinary incontinence were included into the study. All women underwent the same surgical procedure. The samples of pubocervical fascia were taken at the time of surgery. The contents of acid soluble, pepsin soluble, insoluble fraction of collagen, total collagen and collagen crosslinks were measured. The study of pubocervical fascia collagen metabolism included also estimation of collagenase activity. At follow-up done 5 years following surgery, 20 patients reported symptoms of GSUI (study group). Four women were still without symptoms of urine leakage (control group).

RESULTS

The biochemical parameters of pubocervical fascia did not show, statistically significant differences between compared groups.

CONCLUSION

The pubocervical fascia collagen metabolism does not have impact on the results of anti-incontinence surgery.

The rhesus macaque as an animal model for pelvic organ prolapse

OBJECTIVE

The purpose of this study was to characterize the pelvic floor of the rhesus macaque as an experimental model for human pelvic organ prolapse and to initiate an evaluation of the effects of estradiol and progesterone on the rhesus paravaginal attachment.

STUDY DESIGN

Histologic specimens were prepared from the paravaginal attachment of 13 oophorectomized rhesus macaques. Three animals were treated with estradiol; 6 animals were treated with estradiol and progesterone, and 4 animals were untreated (hormone deprived). Immunocytochemistry was used to localize steroid receptors in the paravaginal attachment.

RESULTS

Spontaneous pelvic organ prolapse was observed in rhesus macaques. The paravaginal attachment is comprised of dense collagen and elastic fibers that infiltrate the levator ani muscle. The fibroblasts of this attachment are estrogen and progesterone receptor positive, and the receptors are hormone responsive.

CONCLUSION

The rhesus macaque has pelvic floor anatomy that is similar to women and makes an excellent experimental model for the study of prolapse. The rhesus paravaginal attachment is ligamentous and hormone sensitive. Its fibroblast activity may be modified by estrogen treatment in a manner similar to that reported in human pelvic connective tissue. The connective tissue of the paravaginal attachment interdigitates with the levator ani muscle cells, which suggests that this muscle plays a critical role in pelvic floor support.

A review of the tension-free vaginal tape procedure: outcomes, complications, and theories

In the last century, the pathophysiology of stress urinary incontinence (SUI) has been investigated and several surgical techniques have been utilized for cure. The most recent evolution in the study of SUI is the minimally invasive tension-free vaginal tape (TVT) procedure, which can be done under local anesthesia and intravenous sedation and is individualized for each patient. The procedure recreates the "hammock" of the anterior vaginal wall and endopelvic fascia with a mesh tape of polypropylene. The cure rates of the initial studies are equal to or better than other anti-incontinence procedures, and the permanent supportive mesh is very well tolerated. The TVT creates a backboard on which the urethra compresses itself when it rotates posteriorly during cough or stress. The procedure accomplishes subjective and objective cure without elevating the bladder neck or altering urethral mobility.

Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse

OBJECTIVE

The aim of this study was to identify imaging markers for genuine stress incontinence and pelvic organ prolapse by using magnetic resonance imaging and reconstructed 3-dimensional models.

STUDY DESIGN

Thirty women were studied, 10 with prolapse, 10 with genuine stress incontinence, and 10 asymptomatic volunteers. Axial and sagittal T1 and T2 weighted pelvic magnetic resonance scans were obtained with the patient in the supine position. Source images were measured to determine levator hiatus height, bladder neck to pubococcygeal line, levator plate angle, and perineal descent at rest and maximum Valsalva. Manual segmentation and surface modeling was applied to build 3-dimensional models of the organs. The 3-dimensional models were measured to determine levator muscle volume, shape and hiatus width, distance between symphysis and levator sling muscle, posterior urethrovesical angle, bladder neck descent, and levator plate angle.

RESULTS

The 3 groups of subjects were comparable in age, parity, and body mass index. In the control, genuine stress incontinence, and prolapse groups, the menopausal rate was 40%, 60%, and 55% (P =.7). In the same order, significant mean 2-dimensional measures were: resting bladder neck descent of 24, 17, and 3 mm (P <.005), straining levator plate angle of -4.3, -11.5, and -31 degrees (P =.01), straining levator hiatus height of 48.5, 51.1, and 65.3 mm (P <.005), and straining perineal descent of 17.2, 22.5, 27.2 mm (P =.02). Similarly ordered mean 3-dimensional parameters showed levator volumes of 32.2, 23.3, and 18.4 cm(3) (P <.005); hiatus widths of 25.7, 34.7, and 40.3 mm (P <.005); left levator sling muscle gaps of 15.6, 20.3, and 23.8 mm (P =.03), right levator sling muscle gaps of 15.6, 22.5, and 30.8 mm, (P = 0.003), and levator shape (90%, 40%, and 20% dome shaped; P <.005).

CONCLUSION

Both 2-dimensional magnetic resonance images and 3-dimensional models yield findings that differ among asymptomatic subjects compared with those with genuine stress incontinence and prolapse. Our 3-dimensional data demonstrate a statistically significant continuum in levator volume, shape, and integrity across groups of asymptomatic, genuine stress incontinence, and prolapse subjects.

Urogenital aging--a hidden problem

Urogenital problems in the elderly female population are experienced by one third of women from the age 50 years and onward. Symptoms from the lower urinary tract include incontinence, urethritis, and recurrent urinary tract infections. Atrophic changes within the bladder neck and urethra could be corrected by estrogen administration even at doses so low that endometrial proliferation is avoided. Hence such estrogens could be given without progestogen comedication. Control of micturition is a complex process of which estrogen deficiency is only one of several factors. The aging process with subsequent changes in membrane permeability, neuromuscular function, and collagen synthesis contributes to the local problems of control of micturition. In addition, the central control may also be affected by degenerative changes of the nervous system. Vaginal symptoms comprise dryness of vagina, dyspareunia, and recurrent vaginitis often followed by a foul odor and discharge. The microflora with lactobacilli and low pH as seen in fertile women is gradually replaced by a mixed germ flora including several of the pathogenic organisms common in urinary tract infections. Vaginal pH increases from around 4 to between 6 and 7. It is a puzzling fact that the urogenital tissues seem to be more "sensitive" to estrogens than other tissues. Conformational changes of the estrogen receptor(s) brought about by the local cytokine milieu is one possibility to explain the situation. The systemic absorption of low-dose estrogen preparations is dependent on the status of the vaginal mucosa. Absorption is high when the vaginal mucosa is atrophic and gradually decreases (but not to zero) as the vaginal mucosa matures under estrogen influence.