Local Oestrogen for Pelvic Floor Disorders: A Systematic Review

ObjectiveThe decline in available oestrogen after menopause is a possible etiological factor in pelvic floor disorders like vaginal atrophy (VA), urinary incontinence (UI), overactive bladder (OAB) and pelvic organ prolapse (POP). This systematic review will examine the evidence for local oestrogen therapy in the treatment of these pelvic floor disorders.Evidence AcquisitionWe performed a systematic search in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the non-MEDLINE subset of PubMed from inception to May 2014. We searched for local oestrogens and VA (I), UI/OAB (II) and POP (III). Part I was combined with broad methodological filters for randomized controlled trials (RCTs) and secondary evidence. For part I and II two reviewers independently selected RCTs evaluating the effect of topical oestrogens on symptoms and signs of VA and UI/OAB. In part III all studies of topical oestrogen therapy in the treatment of POP were selected. Data extraction and the assessment of risk of bias using the Cochrane Risk of Bias Tool was undertaken independently by two reviewers.Evidence SynthesisThe included studies varied in ways of topical application, types of oestrogen, dosage and treatment durations. Objective and subjective outcomes were assessed by a variety of measures. Overall, subjective and urodynamic outcomes, vaginal maturation and vaginal pH changed in favor of vaginal oestrogens compared to placebo. No obvious differences between different application methods were revealed. Low doses already seemed to have a beneficial effect. Studies evaluating the effect of topical oestrogen in women with POP are scarce and mainly assessed symptoms and signs associated with VA instead of POP symptoms.ConclusionTopical oestrogen administration is effective for the treatment of VA and seems to decrease complaints of OAB and UI. The potential for local oestrogens in the prevention as well as treatment of POP needs further research.研究目的：绝经后体内雌激素水平下降是阴道萎缩（vaginal atrophy, VA）、尿失禁（urinary incontinence, UI）、膀胱过度活动症（overactive bladder, OAB）及盆腔器官脱垂（pelvic organ prolapse, POP）等盆底功能障碍性疾病的潜在病因。本系统综述将探讨局部雌激素治疗此类盆底功能障碍性疾病的相关证据。 证据获取：本研究于建库至2014年5月期间，对MEDLINE、EMBASE、考克兰对照试验中心注册库（Cochrane Central Register of Controlled Trials）及PubMed非MEDLINE子库进行系统性检索。检索策略涵盖局部雌激素与VA、UI/OAB及POP相关内容。其中研究组I采用针对随机对照试验（randomized controlled trials, RCTs）及二次证据的宽泛方法学筛选标准。针对研究组I与II，由两名研究者独立筛选评估局部雌激素对VA及UI/OAB症状与体征影响的RCTs；针对研究组III，则筛选所有评估局部雌激素治疗POP效果的研究。两名研究者独立完成数据提取及采用考克兰偏倚风险评估工具开展偏倚风险评价。 证据综合：纳入研究在局部给药途径、雌激素类型、给药剂量及治疗疗程等方面存在异质性。研究采用多种指标评估客观与主观结局。总体而言，与安慰剂组相比，阴道雌激素给药可改善主观结局、尿动力学结局、阴道成熟度及阴道pH值。不同给药途径间未观察到显著差异，低剂量给药即已显现获益。针对POP患者局部雌激素治疗效果的研究较为匮乏，且现有研究多评估与VA相关的症状与体征，而非POP本身的相关症状。 结论：局部雌激素给药可有效治疗VA，且似乎可缓解OAB及UI相关主诉。局部雌激素在POP预防与治疗中的应用潜力仍需进一步研究。