Ageing of the female pelvic floor: towards treatment a la carte of the “geripause”

Abstract

When you are old and grey and full of sleep, And nodding by the fire, take down this book, And slowly read, and dream of the soft look, Your eyes had once, and of their shadows deep. William Butler Yeats The study of menopause and female ageing "geripause" is receiving much attention lately from the health care community for three main reasons [1-3]. The first is the global increase in female life expectancy as a result of improved health awareness and services with continuing reduction of adult mortality, progressive transition from high to low fertility, and recent socioeconomic affluence in most countries. This unprecedented demographic change, which started in the developed world in the 19th century and more recently in developing countries, allowed women to experience menopausal manifestations during approximately one third of their lifespan and reach the geripause.Secondly, the process of medicalization within the broader context of the dominance of health as a cultural preoccupation in recent societies and women's motivation by personal concerns and cultural forces to take more control of the effects of menopause and/or ageing on their bodies has resulted in increasing use of female sex hormones as a replacement therapy. Finally, there is a growing public and medical concern about the serious adverse effects of estrogen/progestin replacement therapy in old postmenopausal "geripausal" women that had been recently reported in the Women's Health Initiative Trial. This is accompanied by considerable interest in the contemporary biomedical literature, in particular, about the prevalence, detrimental effects, and management of support-related pelvic floor dysfunction (pelvic organ prolapse, urinary incontinence, and fecal incontinence) in the geripausal population. There seems to be no consensus, however, whether the exact underlying mechanism is normative ageing, falling circulating estrogen levels caused by menopausal ovarian failure, or a combination of both factors [3][4][5][6][7][8][9].It is widely believed that estrogen deprivation at the climacteric is primarily responsible for support-related pelvic floor dysfunction in geripausal women. This assumption is based on the detection of estrogen receptors in the components of continence-maintaining and supportive pelvic floor structures in premenopausal women and experimental animals [3][4][5][6]. In turn, estrogen replacement had been extensively used to prevent or restore the decline in pelvic floor support and/or deterioration of urinary and fecal control after the menopause but without critical analysis of the long-term cure rates or evidence-based improvement in clinical outcome after treatment in most studies [7]. Paradoxically, a recent meta-analysis and a

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“…Oestrogen deficiency at menopause is widely considered as a contributing factor for pelvic floor dysfunction due to presence of oestrogen receptors in supportive pelvic floor disorders although long-term benefits after oestrogen replacement has not been analysed in most studies. 6 …”

Obesity and urinary incontinence in women: is the black box becoming grayer?

“…Ghrelin is a recently discovered 28 amino acid peptide hormone that was initially identified as an endogenous ligand for growth hormone (GH) stimulating hormone receptor in rat and human stomach and is the only known orexigenic gut hormone [8,9]. Levels of circulating ghrelin have been noted to increase before meals and fall rapidly after eating [8].…”

“…A decrease in circulating ghrelin has also been found following bypass operations and may be responsible for the long-term weight loss following bariatric surgery. Ghrelin receptors are expressed in the pituitary gland and hypothalamus as well as a wide variety of peripheral tissues including the urethra, urinary bladder, and anal canal of rats [8][9][10]. Recent animal studies have shown that ghrelin also has important anti-aging function on the pelvic floor [9].…”

“…Ghrelin receptors are expressed in the pituitary gland and hypothalamus as well as a wide variety of peripheral tissues including the urethra, urinary bladder, and anal canal of rats [8][9][10]. Recent animal studies have shown that ghrelin also has important anti-aging function on the pelvic floor [9]. Ghrelin administration reversed the expression of aging markers in the pelvic floor supportive structures of ovariectomized old rats either by acting through target organ ghrelin receptors or by stimulating GH release.…”

“…Ghrelin also inhibited the in vitro contractile response of rat detrusor muscle, and the relaxant effect was more pronounced in strips obtained from lean rats than from obese rats [10]. It is therefore possible that the decrease in circulating ghrelin associated with obesity could adversely affect the urethral support and detrusor contractility in obese women to increase the risk of SUI and OAB, respectively [9,10].…”