Prasterone may reduce UTI risk for postmenopausal women with vulvovaginal atrophy
Key takeaways:
- Postmenopausal women with vulvovaginal atrophy treated with prasterone had lower UTI prevalence.
- Women who used aromatase inhibitors and those with diabetes also derived benefit from prasterone treatment.
Postmenopausal women with vulvovaginal atrophy treated with intravaginal prasterone for at least 12 weeks were nearly 50% less likely to develop a urinary tract infection compared with untreated women, researchers reported in Menopause.
The prevalence of urinary tract infections (UTI) for postmenopausal women increases with age and data show continuous low-dose or single-dose antibiotic prophylaxis can reduce risk for UTI recurrence by 25%; however, an antibiotic regimen is also associated with adverse effects such as oral and vaginal candidiasis, Rachel Rubin, MD, MSCP, urologist and sexual medicine specialist in the department of urology at Georgetown University Hospital, and colleagues wrote in the study background.
“Preclinical and clinical evidence has shown that androgens also play a role in the maintenance of genitourinary health. The effect of androgens may be expressed through their conversion to estrogen by aromatase and their direct effect on androgen receptors expressed in female genitourinary structures,” the researchers wrote. “Both androgens and estrogens can be synthesized from dehydroepiandrosterone (DHEA or prasterone) in the peripheral tissues.”
Rubin and colleagues conducted an observational, retrospective study analyzing 545,246 postmenopausal women with at least two medical claims for vulvovaginal atrophy or dyspareunia matched with women without those diagnoses, using claims data between February 2015 and January 2020 (mean age, 61.6 years).
Researchers matched 22,245 women treated with intravaginal prasterone (Intrarosa, Millicent Pharma), a synthetic DHEA, for at least 12 weeks with women without any prescribed vulvovaginal atrophy-related treatment (mean age, 58.4 years) to evaluate intravaginal prasterone as a prophylaxis to reduce UTI risk.
Overall, 22.16% of women with vulvovaginal atrophy and 7.44% of women without vulvovaginal atrophy had at least one UTI episode the year after the index date.
Women with vs. without diabetes had a higher UTI prevalence, regardless of vulvovaginal atrophy status, and UTI prevalence increased with age for women with and without vulvovaginal atrophy. In addition, UTI prevalence was higher for women with vs. without vulvovaginal atrophy across all age groups (P < .0001).
Across all age groups, women treated with intravaginal prasterone had lower UTI prevalence compared with women left untreated (6.58% vs. 12.3%; P < .0001). Researchers observed the highest difference in UTI prevalence for those treated and not treated with intravaginal prasterone among those aged 65 to 74 years (7.15% vs. 16.2%; P < .0001).
In the subgroup analysis, women who used aromatase inhibitors (4.9% vs. 9.79%; P < .01) and those with diabetes (14.59% vs. 20.48%; P < .0001) treated with intravaginal prasterone also had lower UTI prevalence compared with untreated counterparts. Women who used aromatase inhibitors (0.07 vs. 0.11; P < .0001) and those with diabetes (0.207 vs. 0.245; P < .0001) treated with intravaginal prasterone also had fewer UTI episodes compared with untreated counterparts.
“Our findings highlight the need for more proactive screening and treatment of postmenopausal women for vulvovaginal atrophy/genitourinary syndrome-related signs and symptoms for earlier diagnosis and treatment,” the researchers wrote. “This study suggests that intravaginal prasterone is a good candidate for UTI prophylaxis in postmenopausal women, including women on aromatase inhibitors and those with a diabetes history.”
Perspective
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In this study, the authors nicely outline the significant occurrence of UTIs among postmenopausal women. They also comment on the debilitating and even occasionally life-threatening sequelae these infections present to many of these older women.
Prasterone, another term for synthetic dehydroepiandrosterone, was introduced to our armamentarium for therapy of genitourinary syndrome of menopause approximately 8 years ago. The late Fernand Labrie, MD, PhD, pioneered its use as an alternative to vaginal estrogens. There is a considerable amount of work available showing its androgenic activity complements the activity from intracrine conversion to estrogen. We also have good data showing no significant elevations in either systemic estrogen or androgens from its intravaginal use.
This study shows that vaginal prasterone therapy is quite effective in decreasing UTIs, similar to the effects known for vaginal estrogens. Additionally, it works well for women with diabetes and those prescribed aromatase inhibitors, who often have significant vulvovaginal atrophy because of their very low systemic estrogen levels. Although we know that women using vaginal estrogens have very minimal absorption of their estrogen, many oncologists are still afraid of their use in patients with breast cancer. Thus, prasterone has a significant potential for use in these patients, if they are not allowed use of vaginal estrogens. The Menopause Society included prasterone in its guidelines for the use of vaginal estrogens in breast cancer survivors in its 2018 recommendations.
The authors also very nicely point out that many women are not receiving care for their genitourinary syndrome of menopause issues, and thus we should encourage these women to seek help, and for their general medical providers to provide that care as appropriate.
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