Hormones and the Pelvic Floor
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Did you know that estrogen actually suppresses enzymes that break down collagen? Well it is true. A class of enzymes called metalloproteinases (MMP13 in particular) degrade the collagen that supports the pelvic organs and may contribute to prolapse of the pelvic organs over time (as an aside… one has to wonder what they are doing to our skin). In February 2009 the journal Biology of Reproduction published a paper that demonstrates that estrogen and progesterone are suppressors of these collagen attacking enzymes. Add this to the list of quality of life benefits we can ascribe to hormone replacement.
What about testosterone? We now that androgens (like testosterone) promote skeletal muscle hypertrophy (growth). We know that the levator ani, urethral sphincter, and anal sphincter all have androgen receptors. We know that a weak pelvic floor is associated with numerous types of lower urinary tract, bowel, and pelvic organ support disorders. Furthermore we know that testosterone levels are lower in women after the menopause. Products like Estrotest (combined estrogen and methyl-tesosterone) have been produced to replace testosterone in this population and may be helpful for postmenopausal women with low libido. Should we be supplementing testosterone routinely after the menopause to prevent pelvic floor dysfunction? Should we be replacing testosterone among women who have symptoms related to pelvic floor dysfunction? Would testosterone supplementation be useful during a program of pelvic floor rehabilitation?
Risks of testosterone supplementation among postmenopausal women.
The main concern with supplementing testosterone among postmenopausal women is that this hormone may increase the individuals’ risk of breast cancer. Like the debate over estrogen replacement we are balancing quality of life issues (e.g. relief from hot flashes and night sweats) with quantity of life issues (risk of heart attack, stroke, breast cancer). Given the breast cancer concern I don’t think we can make the argument for long term testosterone supplementation for pelvic floor dysfunction at this point. Short term, low dose, physiologic supplementation of testosterone during a rigorous 6-12 week program of pelvic floor training may be of benefit and is unlikely to confer significant risk.
The effect of aging on the pelvic floor is no doubt complex. It is clear that sex hormones have a direct effect on the pelvic floor. Estrogen replacement with or without progesterone may slow the degradation of collagen through out the body while preserving the normal elastic integrity of the uro-genital tissues. Likewise, waning testosterone levels seem to promote atrophy of skeletal muscle throughout the body including the pelvic floor. The extent to which this can be mitigated by androgen replacement remains to be seen, however, any benefit we discover will, like all forms of therapy, be balanced by some finite risk.