The WHI Results on Urinary Incontinence
The WHI Results on Urinary Incontinence
Abstract & Commentary
Leon Speroff, MD, Professor of Obstetrics, and Gynecology, Oregon Health Sciences University, Portland, is Editor for OB/Gyn Clinical Alert
Synopsis: Conjugated equine estrogen alone and CEE + MPA increased the risk of urinary incontinence among continent women and worsened the characteristics of urinary incontinence among symptomatic women after 1 year.
Source: Hendrix SL, et al. JAMA. 2005;293:935-948.
Results from the 2 canceled arms of the Women’s Health Initiative (WHI) were reported for the presence of urinary incontinence after one year of treatment in those women without incontinence at baseline and for the severity of urinary incontinence in those who reported incontinence upon entry to the study. Findings were as follows:
The use of hormone therapy for longer periods of time was examined in an 8.6% subset on treatment for 3 years, and there did not appear to be any meaningful changes in the relative risks.
Comment by Leon Speroff, MD
This contribution from the WHI does not disagree with the overall results in previous literature. All of these results have been contrary to what seemed like a logical conclusion, that estrogen treatment would reduce or prevent incontinence by improving or avoiding the atrophy of the genito-urinary tract that follows menopause.
It has been argued that genuine stress incontinence is not affected by treatment with estrogen, whereas others have contended that estrogen treatment improves or cures stress incontinence in more than 50% of patients due to a direct effect on the urethral mucosa.1-3 However, a meta-analysis concluded that improvement was reported only in nonrandomized studies.4 Two randomized trials dedicated to this clinical problem failed to demonstrate a beneficial effect of estrogen treatment.5,6 Most cases of urinary incontinence in elderly women are a mixed problem with a significant component of urge incontinence that clinicians believed to be improved by estrogen therapy. However, the Heart and Estrogen-progestin Replacement Study (HERS) randomized trial indicated a worsening of incontinence with hormone therapy for both urge and stress incontinence, and the Nurses’ Health Study reported a small increase of incontinence in hormone users.7,8
These results seem somewhat surprising, and indicate that the mechanism for stress incontinence is not only unresponsive to estrogen’s beneficial effects on epithelium, but even worsened. Although the adverse effects were more prominent in the oldest women in the WHI, the impact was observed in younger women as well. This certainly challenges the urogynecologists to study this mechanism and understand the physiology behind these epidemiologic results.
One could nitpick this report from the WHI. For example, the participants in the 2 trials were not identical (more reported daily incontinence in the estrogen only arm, and the estrogen only arm had more elderly women), and current users of hormone therapy upon entry to the study did not have an adverse effect on incontinence (but the numbers were small). It is intriguing to wonder why the women who were currently using hormone therapy at baseline did not report this adverse effect. However, the overall results are consistent with the literature on this subject, and we should accept that postmenopausal hormone therapy carries a small increase in worsening or onset of incontinence. Most importantly, the reason why needs understanding.
References
- Wilson PD, et al. Br J Obstet Gynaecol. 1987;94:568-574.
- Bhatia et al. Obstet Gynecol. 1989;160:176-181.
- Goes VR, et al. Clin Exp Obstet Gynecol. 2003;30:103-106.
- Al-Badr A, et al. J Obstet Gynaecol Can. 2003;25:567-574.
- Fantl JA, et al. Obstet Gynecol. 1996;88:745-749.
- Jackson S, et al. Br J Obstet Gynaecol. 1999;106:711-718.
- Grady D, et al. Obstet Gynecol. 2001;97:116-120.
- Grodstein F, et al. Obstet Gynecol. 2004;103:254-260.
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