Role of Estrogen

The onset, or worsening of bladder problems around the time of the menopause, or a few years later often occurs and is thought to be due to the effect of estrogen deficiency on the bladder, vagina and pelvic floor muscles. Although many women report an improvement in bladder symptoms when estrogen is taken in the form of Hormone Replacement Therapy (HRT), studies have shown mixed results. However, the use of locally acting, vaginal estrogen clearly helps and is recommended by the National Institute of Clinical Excellence NICE (ref 2).

Vaginal estrogen can be taken even if systemic HRT is not recommended, or not desired, since vaginal estrogen is of very low dose and acts locally in the vagina and bladder, with minimal absorption into the circulation, while systemic HRT circulates throughout the body.

Vaginal estrogen is available in the form of a very small vaginal tablet inserted with an applicator, vaginal creams, pessaries or a vaginal ring. Treatment should be long term since the consequences of the menopause, ie lack of estrogen, on the vagina and bladder can continue indefinitely, and current recommendations are that treatment can be continued indefinitely as long as annual review with a healthcare professional is arranged.

Bladder symptoms most likely to respond to vaginal estrogen include frequency, nocturia, urgency and urge incontinence (ref 3, ref 4) while the vaginal symptoms most likely to respond include dryness, irritation, itch and discomfort during sexual activity. Systemic HRT is extremely effective at controlling or reducing the menopausal symptoms of flushes, sweats, joint aches, sleep disturbance and mood changes and may help the bladder and vaginal symptoms, but about 10-25% of women taking systemic HRT may still have bladder and/or vaginal symptoms and will require vaginal estrogen in addition (ref 5).These can be taken in combination safely, without one interfering with the other.