Investigation of the Effect of the Female Urinary Microbiome on Incontinence

Overactive bladder (OAB) syndrome is characterized by the symptom complex of urinary urgency,
usually with associated frequency and nocturia, with or without urgency urinary incontinence
in the absence of infection or other pathology. OAB affects approximately 31% of women over
the age of 65. Vaginal estrogen, a well-documented treatment for OAB in hypoestrogenic women,
has been shown to improve symptoms of frequency, urgency and urgency urinary incontinence
(UUI). Several theories have been proposed to explain the mechanism underlying estrogen's
effect on lower urinary tract symptoms (LUTS). The investigators propose that estrogen
treatment influences bacterial communities (microbiomes) in the vagina and bladder and alters
urothelial and vaginal (AMPs) thereby improving OAB symptoms in hypoestrogenic women.

Long-standing medical dogma has been replaced by clear evidence that a female urinary
microbiome (FUM) exists. The investigators recently reported that the FUM in women without
OAB is less diverse than the FUM of women with OAB. The investigators soon will report that
FUM status stratifies women with OAB into treatment response groups and women with less
diverse FUMs are more likely to respond to anti-cholinergic OAB therapy (Thomas-White et al.,
in preparation). This suggests that the FUM is a factor in lower urinary tract symptoms
(LUTS) and that FUM diversity contributes to LUTS and treatment response, like the vaginal
microbiome and its contribution to vaginal symptoms.

In hypoestrogenic women, the vaginal microbiome shifts from low diversity communities,
commonly dominated by Lactobacillus, to more diverse communities dominated by anaerobes; this
change can be reversed with estrogen treatment. Since the FUM of women with OAB includes
bacteria similar to those of the vaginal microbiome (e.g. Lactobacillus, Gardnerella, and
diverse anaerobes), the investigators reason the FUM would respond similarly to estrogen and
become less diverse. Although transvaginal medications likely alter nearby bacterial niches
(e.g. the bladder), no study has reported the urinary microbiomic response to vaginal
estrogen.

While almost nothing is known about urinary/vaginal microbiome interplay, even less is known
about immune response modulation in the bladder and vagina. However, estrogen reduces the
subsequent urinary tract infection (UTI) rate in hypoestrogenic women affected by recurrent
UTI, and estrogen induces urothelial antimicrobial peptide (AMP) expression. Since AMPs
exhibit microbicidal activity, stimulate inflammation, and facilitate epithelial barrier
homeostasis, estrogen may work through AMPs as mediators to optimize microbial equilibrium.

The investigators hypothesize that, following estrogen treatment of hypoestrogenic women with
OAB, symptom improvement will be associated with 1) reduced FUM diversity, 2) alteration of
other FUM characteristics and 3) increased AMP levels. The investigators propose two specific
aims:

Aim 1: To compare pelvic floor microbiome (PFM) diversity and AMP levels before and after
estrogen treatment in hypoestrogenic women with OAB symptoms.

Aim 2: Determine if FUM characteristics correlate with OAB symptoms.

Inclusion Criteria:

- Women who present with symptoms of OAB, defined as a condition characterized by
urgency, with or without urgency incontinence, usually with frequency and nocturia in
the absence of obvious pathology or infection [9], with atrophic vaginitis.

- Postmenopausal by history (i.e., defined as twelve months or greater since last
menstrual period), surgical menopause with removal of bilateral ovaries, or age over
55 with a previous hysterectomy (without removal of bilateral ovaries).

- English language skills sufficient to complete questionnaires

- Clinical indication for vaginal estrogen use (i.e., hypoestrogenic findings on
physical examination)

- Patients not currently receiving vaginal estrogen therapy

Exclusion Criteria:

- Patients currently on systemic hormone replacement therapy (HRT) or who have been on
HRT within the past three months

- Patients with current diagnosis or history of estrogen dependent malignancies (e.g.,
breast or endometrial malignancies)

- Contraindication or allergy to estrogen therapy

- Insufficient English language skills to complete study questionnaires

- Women with active, standard culture positive urinary tract infection at baseline
assessment, or those with a urine dip positive for leukocytes and nitrates on straight
catheterized sample.

- Patients who have received antibiotics within the past two weeks

- Patients with stage 3 or 4 pelvic organ prolapse based on the pelvic organ prolapse
quantitation system (POP-q)

- Patients unwilling to use vaginal estrogen preparation

- Patients currently on anticholinergic medications or who have received anticholinergic
medications within the past three months

- Patients who have previously failed two medications for treatment of OAB or have
previously received more advanced treatment for OAB including intra-vesicle botulinum
toxin injections, posterior tibial nerve stimulation, or implantation of a sacral
neuromodulator

- Patients wishing to start anticholinergic medication at the initial encounter

- Undiagnosed abnormal genital bleeding

- Active deep vein thrombosis (DVT), pulmonary embolism (PE), or a history of these
conditions

- Active arterial thromboembolic disease (for example, stroke and MI), or a history of
these conditions

- Known liver dysfunction or disease

- Known protein C, protein S, or antithrombin deficiency or other known thrombophilic
disorders