When her eight-year-old son Lucas stopped wetting the
bed, Marilou F was thrilled to bid urinary incontinence
(UI) good riddance. Now, 20 years later, the 58-year-old
has to deal with it on a personal level, as it is a symptom
associated with menopause. Unfortunately for her, the
hormone therapy that she's on, which was once thought
to improve the symptoms of UI, has now been shown to actually
increase both the incidence and the severity of this condition
in healthy postmenopausal women.
The study published February 23
in the Journal of the American Medical Association
(JAMA), used a re-analysis of the infamous Women's
Health Initiative (WHI) study, which first disproved
the supposed benefits of hormone therapy. Once viewed
as a modern miracle pill for the aging woman, the WHI
study demonstrated that in addition to increasing the
risk of breast cancer, hormone therapy could lead to
cardiovascular disease.
REVISITING
WHI
The JAMA study was engineered by Dr Susan Hendrix
and her colleagues from Wayne State University School
of Medicine in Detroit, Michigan. They analyzed data
from 23,296 women who were enrolled in the WHI study
and who had UI. The women had been randomized to receive
either estrogen alone, estrogen with progestin, or placebo.
Among those who had been fully
continent at baseline, both estrogen alone and the combination
therapy were associated with an increased risk of incontinence
at one year. Estrogen alone produced the most marked
effect, increasing the incidence of stress incontinence
by a factor of 2.15, and of urge incontinence by a factor
of 1.32. Estrogen with progestin increased the risk
of stress incontinence by a factor of 1.87, but had
no apparent effect on rates of urge incontinence.
In addition, women who were already
suffering symptoms of incontinence at the outset of
the study tended to report a worsening of symptoms after
beginning hormone therapy. Those in the active treatment
groups were more likely than subjects on placebo to
report that incontinence hindered their daily activities.
Moreover, these trends persisted in a small subset of
women who were followed for three years.
FROM
BAD TO WORSE
The WHI trials were stopped because the treatment risks
appeared to outweigh its benefits. These findings tilt
the scales even further against hormone therapy, said
the authors in their study. "These results from a large,
double-blind, placebo-controlled, randomized clinical
trial, conducted in multiple centres with an ethnically
diverse group of healthy postmenopausal women, indicate
that menopausal hormone therapy use does not confer
protection against any type of UI." They believed that
"On the contrary, both conjugated equine estrogen (CEE)
alone and CEE plus medroxyprogesterone acetate increased
risk of new onset UI among continent women and worsened
the characteristics of UI among symptomatic women. Considerations
regarding the use of hormone therapy by postmenopausal
women for any duration should incorporate the current
findings into the established risks and benefits of
these agents."
In an accompanying editorial, Dr
Catherine DuBeau, a professor of geriatrics at the University
of Chicago, agreed that oral estrogens should no longer
be given to postmenopausal women for the treatment of
incontinence. However, she argued, "this trial is not
the final word on using estrogens to treat UI. Whether
topical estrogens might prove beneficial remains unknown."
JAMA
Feb 23, 2005;293:935-48
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