Latest HERS Report Links HRT to Increased Risk for Urinary Incontinence

Peggy Peck

April 30, 2003

April 30, 2003 (New Orleans) — Women with a history of cardiovascular disease (CVD) who take estrogen plus progestin may have a significantly higher rate of urinary incontinence than women who don't take the hormones, according to the latest analysis from the Heart and Estrogen/Progestin Replacement Study (HERS) investigators.

"And the risk increases with length of treatment, so women taking estrogen for five years have a five-fold increase in risk while women taking it for a year double the risk," said Jody Steinauer, MD, a research fellow at the University of California in San Francisco. Dr. Steinauer presented the study results here at the 51st annual meeting of the American College of Obstetricians and Gynecologists.

She said that 48% and 54% of the women who took daily estrogen plus progestin developed urge incontinence and stress incontinence, respectively. Only 36% of women taking placebo developed urge incontinence and 38% developed stress incontinence.

The study also gauged the risk for increasing severity of incontinence as judged by numbers of episodes of leaking in a week. Here, too, hormone use was associated with a worsening situation; women in the active therapy arm were twice as likely to have an increase in numbers of leaking events compared with women in the placebo arm.

The results are based on information collected from 1,208 women who had no symptoms of either stress or urge urinary incontinence at baseline.

All of the women in the study had a history of CVD and the average age of the women was 66 years. Women were asked to fill out continence questionnaires at study entry, four months into the study, and again at one year, two years, and four years. The women were randomized in a 1:1 manner to either 0.625 mg of conjugated estrogens plus 2.5 mg of medroxyprogesterone acetate daily or to placebo.

Dr. Steinauer told Medscape that she is not sure why estrogen increases the risk for incontinence but she noted that estrogen does make tissue "more supple and it may be that making it more supple may also make it more relaxed, which decreases bladder control." Or, since the women have CVD, she said "there may be some vascular component in these women that influences the effect of estrogen on incontinence risk."

At one time researchers thought that estrogen could "be used to treat incontinence. This is understandable since there is such a wide network of estrogen receptors in the bladder and throughout the urinary tract. But earlier treatment studies reported no advantage," she said.

Gerald Joseph, MD, medical director of women's services at St. John's Health System in Springfield, Missouri, told Medscape that he is not surprised by this finding. He noted that many surgeons direct women undergoing pelvic reconstructive surgery to use estrogen to promote healing but he said that he has never seen any clinical evidence of benefit.

These latest data should be considered in the context of the entire estrogen picture, Isaac Schiff, MD, chief of Vincent Memorial Hospital, Obstetrics and Gynecology Service, and the Women's Care Division of Massachusetts General Hospital in Boston, told Medscape. "The final sentence has not yet been written."

He noted, for example, that there "is some suggestion that estrogen may be useful for treating women with recurrent urinary tract infections." Dr.Schiff, who, like Dr. Joseph, was not a HERS investigator, presented a perspective on the history of hormone replacement therapy for the Irving Cushner Memorial Lecture at the meeting.

Dr. Schiff is not alone in his willingness to follow estrogen to the end of the story — Dr. Steinauer takes a similar approach. She told Medscape that despite the study results, she still prescribes estrogen for women who have "debilitating hot flashes. Hands down, estrogen is still the best treatment for those symptoms."

ACOG 51st Annual Clinical Meeting: Abstract 10S. Presented April 29, 2003.

Reviewed by Gary D. Vogin, MD

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