Can estradiol vaginal rings be used to treat urinary incontinence and urgency in a postmenopausal woman?

Estradiol Vaginal Rings for Incontinence and Urgency

Estradiol vaginal rings can be used to treat urinary urgency and recurrent UTIs in postmenopausal women, but systemic oral estrogen should never be used as it worsens incontinence. 1

Key Distinction: Route of Administration Matters

The route of estrogen delivery is critical—vaginal and systemic estrogen have opposite effects on urinary symptoms:

Vaginal Estrogen (Including Rings) - Beneficial

• Vaginal estrogen improves urinary urgency, frequency, dysuria, and prevents recurrent UTIs in postmenopausal women 1, 2
• Estradiol vaginal rings specifically reduced recurrent UTI rates from 80% in untreated women to 51% in treated women (p=0.008) 3
• Vaginal estrogen reduces urinary frequency and urgency by approximately 1-2 fewer voids per 24 hours 1, 4
• The mechanism involves restoring vaginal pH, reducing gram-negative bacterial colonization, and promoting lactobacillus-dominant vaginal flora 1
• Low-dose intravaginal estrogens may be considered to manage genitourinary symptoms of menopause, including urinary symptoms of urgency, dysuria, or recurrent UTI 3

Systemic Oral Estrogen - Harmful

• Systemic oral estrogen therapy (with or without progestin) should NOT be used to treat urinary incontinence, as it worsens incontinence rather than improving it 1
• Oral estrogen alone increases the risk of developing new-onset urinary incontinence with a hazard ratio of 1.53 (95% CI 1.37-1.71) after just 1 year 1
• Combined oral estrogen plus progestin similarly worsens incontinence with a hazard ratio of 1.39 (95% CI 1.27-1.52) 1
• These negative effects persist for at least 3 years of follow-up 1

Specific Effects on Different Urinary Symptoms

Urgency and Frequency

• Vaginal estrogen improves urgency symptoms in over 80% of postmenopausal women 5
• Frequency is reduced in approximately 50% of patients treated with vaginal estriol 5
• The sensation of urgency improves with vaginal estrogen, though urge incontinence improvement may be similar to placebo 6

Stress Incontinence

• Vaginal estrogen may improve stress incontinence compared to placebo, with a risk ratio of 0.74 (95% CI 0.64-0.86) 1
• However, stress incontinence does not consistently improve with estrogen therapy 6
• Subjective improvement in stress urinary incontinence symptoms was 82% for grade 1,77% for grade 2, and 69% for grade 3 with vaginal estriol 5

Recurrent UTIs

• Vaginal estrogen prevents recurrent UTIs in postmenopausal women 1, 2
• Estradiol vaginal rings demonstrated significant reduction in recurrent UTI rates (51% vs 80% in untreated women, p=0.008) 3

Safety Profile

• Vaginal estrogen does not increase serum estrogen levels and is not associated with increased risk of breast cancer recurrence, endometrial hyperplasia, or endometrial carcinoma 1
• Adverse effects are minimal—approximately 2% of patients experience vaginal itching and burning sensations 5
• Long-term systemic estrogen carries significant risks including stroke (HR 1.34-1.36), DVT (HR 1.47-1.88), pulmonary embolism, gallbladder disease, and dementia 1

Clinical Implementation

When to Use Vaginal Estrogen Rings

• Postmenopausal women with urinary urgency, frequency, or dysuria 1, 2
• Women with recurrent UTIs (≥2 infections per year) 3, 1
• Women with genitourinary syndrome of menopause (GSM) 2
• Women who have undergone risk-reducing bilateral salpingo-oophorectomy 3

Common Pitfalls to Avoid

• Do not prescribe systemic oral estrogen for urinary symptoms—it will worsen incontinence 1
• Do not assume all estrogen formulations have the same effect on urinary symptoms 1, 2
• Do not overlook vaginal estrogen as first-line treatment for urgency and frequency in postmenopausal women 4
• Recognize that around 50% of postmenopausal women experience urinary urgency attributable to estrogen deficiency 4