Menopausal Syndrome
A 2012 review of the literature on
the epidemiology of UI in women and the effects of HRT on urinary
leakage found that UI was a common symptom during
menopause.33 Decreased estrogen concentrations
associated with menopause have been considered to be responsible for the
increasing prevalence of SUI in aging women, possibly because vaginal
tissue is weaker in postmenopausal women than in premenopausal women and
thus becomes a risk factor for the deterioration of continence
mechanisms and consequently the efficacy of anti-incontinence
surgery.34, 35 Although menopausal syndrome is a
recognized risk factor for SUI, scant study evidence describes the
effects of menopausal syndrome on surgical outcomes. A retrospective
study from Turkey that investigated mesh erosion after tension free
vaginal tape (TVT) and transobturator tape (TOT) found that menopausal
status was a statistically significant factor in patients with mesh
erosion, but was no longer a significant independent risk factor after
multivariate analysis.36 In contrast, our study found
that patients who had a history of menopausal syndrome within 1 year
prior to the index operation were more likely to develop surgical
complications. Moreover, menopausal syndrome or HRT were significantly
associated with the risk of 5-year surgical complications (aHR, 1.794;
p=0.0390), although the association was not significant in patients aged
≤65 years (aHR, 2.164; p for interaction=0.3750). Estrogen increases
angiogenesis, which is important for nourishing vaginal tissue. However,
a negative correlation has been observed between angiogenic activity and
mesh-induced inflammation in mice implanted with steroid-coated
polyvinylidenfluoride (PVDF) meshes.37 At menopause,
decreased estrogen levels lead to a reduction in angiogenesis and
therefore poor nourishment of vaginal tissue, which would increase the
possibility of surgical complications.
Hormone Replacement Therapy
International guidance recommends conservative therapies as the
first-line management of women with SUI, such as lifestyle changes and
behavioral therapies, weight loss, and supervised pelvic floor muscle
training.11, 12 Estrogens are believed to be
beneficial in the treatment of SUI; starting estrogen replacement soon
after menopause may be effective in preventing or delaying the onset of
SUI.35, 38
HRT is a common medical treatment used to supplement women with hormones
that are lost during the menopausal transition. Conventional HRT
includes an estrogen and progesterone component to relieve the
menopausal syndrome.39 In our study, patients with
diagnosed menopausal syndrome who used HRT within a year prior to
midurethral sling surgery had a significantly higher risk of surgical
complications at 5 years following midurethral sling surgery for SUI
compared with their counterparts who did not have these risk factors. As
patients diagnosed with menopausal syndrome commonly receive HRT to
relieve their symptoms, it is difficult to distinguish between the
effects of HRT and aging-related menopausal syndrome upon the risk of
surgical complications associated with midurethral sling surgery.
Although vaginal estrogen may be effective in preventing or delaying
SUI, no evidence has shown that oral estrogen has benefits in SUI
patients. A retrospective study in 2018 had found that the use of
systemic estrogen may increase the SUI risk.40Estrogens are known to stimulate collagenase activity, which may lead to
degradation of total collagen, especially the most supportive type I
collagen, which may be replaced by weaker immature
collagen.40 The lack of mature collagen might lead to
inadequate support of the vaginal and pelvic structure, especially
postoperatively, increasing the possibility of surgical complications
such as urine retention.