If you’re like most WVFC readers, you keep an eye on our In the News roundup for the latest headlines of interest. Lately, there’ve been a lot of health-related stories, including one that appeared on the Fox News website, about a study indicating a connection between estrogen use and urinary incontinence. We asked urogynecologist Lauri Romanzi, M.D., a member of the WVFC Medical Advisory Board, to share her thoughts about the study and what it might—or might not—mean for you.  –Ed.

Hormones—always a hotspot when it comes to science reporting in the lay press—sparked yet another over-interpretation of a medical study in this month’s issue of the journal Menopause. Published some seven years after the fact, with data from 2004, the report by Dr. Northington of Emory University garnered a headline would have us believe an indisputable cause-and-effect connection between estrogen use and urinary incontinence. This small study relied on questionnaires alone, without corroborative examination or evaluation.

Beneath the alarming headline, the author’s description is appropriately cautious – disclosing glaring weaknesses in the study, including lack of documentation of the type and dose of estrogen used, or whether progesterone—proven to reduce bladder capacity and increase bladder overactivity and irritability in animal studies—was taken along with the estrogen. To presume that estrogen is the culprit, based on a small single questionnaire study, is a bit of a reach. Among medical researchers, this type of clinical correlation barely raises an eyebrow. We know that correlational findings do not prove cause and effect. They simply prove association, if that. To get from association to cause and effect requires the following steps:

A correlational study using thousands of participants and validated questionnaire tools, with appropriately powered subset clinical evaluation examinations followed by:

Prospective randomized double-blind clinical trials, again with enough participants for proper power with which to make definitive clinical recommendations, along with:

Bench research looking at receptor and cell activity with application of variable doses of the medication in question, vis-a-vis the bodily dysfunction in alleged association.

We like to see these studies in duplicate or triplicate, from various centers and various countries. That’s what clinicians worldwide think about when they see a small study with minimal data drawing conclusions from a non-validated set of questions.

Most correlational questionnaire-based studies draw from large pools of participants, in the thousands, and use validated questionnaire research tools. This study shows a far greater relative risk (3-4 times the baseline risk of 1) than the urinary incontinence analysis of the Women’s Health Initiative Trial, which found small but real increases in the risk of developing incontinence after one year of known-dose equine (from pregnant mare’s urine) estrogen “Premarin” with or without the synthetic progestin “Provera,” with probability of developing urinary incontinence in the range of 1.38 to 2.1 relative risk in women who started the trial with no urinary incontinence. The incontinence database for WHI included 23,296 women with documentation of urinary function at baseline and at the one-year mark.

Does the Emory study show a far greater risk because it reported on patients for five years instead of one, or because, relatively speaking, it was a tiny database using a non-validated question set and no knowledge of which hormones were taken in what combination other than “estrogen was used?” Estrogen comes in pills from soy, pills from horse urine, patches, creams and gels, each with variable dosing. Most women with intact uteruses who take menopause hormones take some combination of estrogen and progestational medication, often daily. Progestins may make any given bladder irritable and overactive, possibly even incontinent.

In my experience as a urogynecologist, I’ve seen hundreds of non-hormone taking menopausal women suffering irritative bladder symptoms and urinary incontinence who’ve responded beautifully (but not always) to estrogen administered in low-dose vaginal form and systemically by pill or patch. This common clinical scenario is corroborated in the works of Bergman, Cardozo and Long, showing clear benefit to incontinent menopausal women when estrogen therapy is instituted.

Such a real-life perspective from the flipside of the hormone-incontinence coin begs the validity of the advice at the end of this lay report: to routinely advise women about the urinary incontinence risk of estrogen. Dear Science Editors of Lay Press Publications, Please learn the landscape to which you lay claim. Wait for the corroborative studies that warrant making such a recommendation. That’s what we clinicians will be doing.