Hormone therepy

[Tina B]

We have an 11 year old spayed female BC. She has just been put on hormone therapy to help control her bladder. Sometimes when Tasha is relaxing, urine will leak out. I feel bad for her because she acts like she has done something wrong. We had urine tests, x-rays to rule out stones. Her tests came back with moderate crystals in the urine but not stones. My question is if anyone has had their dog on hormones? What can we expect? Thanks for your help.

[AK dog doc]

Hi Tina

None of my own dogs have been on estrogen, but many of my patients have. There are estrogen receptors on the urethral sphincter muscle (which holds the bladder shut), and in dogs with low estrogen levels (as in spayed females) that means that the muscle isn't getting as much stimulation to stay tight. In addition, low estrogen levels can cause poor vaginal tone. Since in dogs the urethra empties into the vaginal vault, this means that A) the muscle that holds the bladder shut can be a little weak, causing urine leaking, and the poor vaginal tone can lead to urine pooling in the vaginal vault, which then leaks out later as the dog is sitting or lying down.

 

Of all the dogs that I've put on estrogen, none have had any detectable side effects. Not every dog responds, but most do, and I have yet to see a single one of them show so much as an upset stomach. Though high doses of estrogen CAN cause serious problems, the estrogen dosages for incontinence are pretty low - just enough to tighten things up - so there isn't a lot of potential for trouble. Most dogs need to stay on the estrogen to remain continent, but beyond that they seem to do great. If I had a female dog with urinary incontinence, I'd put her on low-dose estrogen without hesitation - and only partly to decrease my clean-up chores. As you've noted, the dog often feels psychologically distressed by the incontinence, but there are also the urine scald issues - both on the external skin and internally (rashing +/- infection in the vaginal vault, which CAN'T be comfortable - plus it's a source of infection to the bladder as well as the vaginal structures themselves.) The last thing is that if the dog smells of stale, rank old urine, sometimes they're a wee bit less cuddly-seeming to the owner (go figure! ) and so the dog gets less attention and more pushing-away, which isn't at all reassuring to them. They're already upset and uncomfortable, so the LAST thing they need is rejection on top of that.

 

Hope that clarifies things a bit!

[diane allen]

My Lucy (appearing all too frequently in this particular section!) has incontinence - has since age 3.5 when I got her. She was first on PPA (phenylpropanolamine) which was satisfactory for awhile; but I was concerned about having to give it daily, and her getting that much of any drug daily.

 

For awhile, we tried a homeopathic remedy, which was working reasonably well until we switched to a raw diet. Apparently the difference in moisture content of the food threw everything off balance. I worked with the company's referring vet for awhile, but admit it was just too much "try this for awhile" and not having success. Talk about clean up AND dog skin/smell problems....ugh.

 

I started her on DES (don't have me to spell out that one) hormone, I believe its 25mg tablets, starting every third day; I now give her two per week (much easier to remember!). The pills are not generally available - my vet clinic has them mixed specifically for them. I'm going to try cutting back a bit this summer (when laundry will dry faster...) to see if we can get it even lower.

 

Doc, another vet (actually Lucy's dentist!) mentioned that he'd put his older female on Premarin, the same hormone given to human women, and only gave it once a week. Since that's not what we were there for, I didn't ask any more - like what the dosage was, etc. Have you heard about this?! I'm just wondering if there's any advantage or disadvantage to use of it.

 

Such a distressing problem for all concerned...

 

diane

[Rebecca, Irena Farm]

Does anybody know of a way to prevent this in spayed females? Ie, a way to maintain and improve that muscle tone without drugs, before there is a problem?

[diane allen]

I'm merely passing along another's thoughts here - so remember you get what you pay for!

 

I have a friend veterinarian, who has a theory that she's working on - but obviously this takes a long time to "prove" and its only her own private little test. She believes that many vets do spay operations with a very small incision - to prevent post-surgical problems (like ripping or chewing out stitches), and so the owners don't freak. In doing so, she thinks that it just takes more pulling and tugging to get all the proper organs out, and that may have some affect on continence later on (don't ask me to do the anatomy lesson here....been too many years!). She has been doing spay operations with a larger incision, with the idea that it might just lessen the problem later.

 

Otherwise, I've never heard of any way to "prevent" it. If only....

 

diane

[Tina B]

Thank you for the reply's. I guess it is part of my little girl getting older. She is lying beside me with her chin on my knee looking up at me. I swear she knows I am telling everyone about her problems.

 

The vet said pretty much what AK Dog Doc has said. The vet did add "It's a girl thing!". Is this what we ladies have to look forward to as we age . We have started Tasha on the estrogen. I hope she isn't on the pills forever. But if she is, it is a small price to pay for her to be happy.

 

I wish there was a way to prevent this. It is too late for my dog but for others who take their dogs to get spayed as pups. Yes, spaying is necessary if you don't want to breed your dog. But if something as simple as making an incision larger helps it should be done.

 

Thanks Tina

[AK dog doc]

Well, it's an interesting theory, but to me it doesn't follow logically. Maybe it's just me, and no doubt a large retrospective study (+/- a prospective one) would have to be done to prove anything one way or another, but I seriously doubt that incision size would make a difference. The reason I say this is, in part, that I spay through a larger incision than "the guys" (my two bosses) do, and while I have not specifically done a per-case analysis, there doesn't seem to be any difference in incontinence rates per number of dogs spayed between them and me. That would also mean that every dog ever spayed by a vet student or a new graduate (who very typically spay through much larger incisions - or they do if they're like I was!) would not be prone to incontinence, but ones spayed by boarded surgeons and more experienced GP's would have higher rates of incontinence. Furthermore, cats are typically spayed through much smaller incisions than dogs are, and they rarely if ever have urinary incontinence issues. Granted they're a different species, but if it was strictly tissue handling issues via small incisions, they'd be MORE prone to incontinence, not less. I personally think this is a species difference related to estrogen responses, not a surgical reaction.

 

As a point of logic, if the cause of estrogen responsive incontinence was tissue handling during the spay, the following things do not make sense, at least to me (with some reiteration from above):

 

1) The incontinence occurs at widely variable intervals post-op, anything from a few weeks (rare) to 10 or more YEARS after the surgery. If it was tissue handling and incision size, that wide a time frame does not make sense. You would have to propose at least two different mechanisms (and very likely more) to explain that disparity, IMO.

 

2) If it were about incision size and tissue handling, why would estrogen supplementation make it go away? All estogen supplementation can do is perform the actions of estrogen in the body. It has no power to retroactively correct "damage" done by the alleged over-handling of the tissues years before.

 

3) Given that small spay incisions are very common and estrogen-responsive incontinence is NOT very common, why do not all or most dogs spayed through a small incision have the problem?

 

4) Why do we not see more urinary incontinence in non-canid species who are spayed through even tinier incisions?

 

5) Every dog ever spayed not just by a student, intern or recent graduate, but also during the course of a C-section or with a pyomentra (often quite huge incisions in all such cases) would then be a dog who should never develop incontinence. I know for certain that at least 3 such patients (C-sections and pyometras) at our clinic have later developed incontinence. These are just ones that I can remember off the top of my head; I'd imagine there are more.

 

6) Not that anyone who has not done surgery would be in any way expected to know this, but IMO, the trauma done by putting traction on the tissues during a spay is FAR less than the trauma done by whelping a litter. If it were me speculating, I'd propose a greater risk of incontinence in brood bitches than in spayed ones, if it were tissue trauma that was the issue. We're not in there with a crane and a winch, after all, it's just our own two hands. Moreover, the length of time you have traction on the relevant part of the uterus is - even in my hands, and I'm a relatively slow surgeon - probably no more than 2 minutes in normal cases. That part is over quite quickly - it's a matter of clamp, ligate, move clamp, ligate again, cut, check for bleeding, lower stump into abdomen - now the tension is off - and check for bleeding again. Pushing a puppy past the urethral orifice (times six) during whelping is surely more trauma and "tissue handling" than that, would you not think?

 

7) Why have I (rarely, it's true) seen older intact bitches that develop estrogen-responsive incontinence (presumably as their normal ovarian production drops off)? These dogs are not spayed at all, so there's no incison size issue.

 

At any rate, at least for me that theory doesn't seem to explain all that. It's an interesting idea, but it doesn't fit with my experience. Mind you, there's plenty I don't know in the world, so it could be I'm wrong, but I'd want to see some concrete numbers before I'd be willing to endorse it.

 

On the Premarin question - I haven't heard this used, but we get our DES formulated at 1 mg, which is given daily for several days and then once to twice weekly in most cases; we have no trouble getting it (have a pharmacy that does it for us routinely) so have not had to use Premarin. I'd have to check the literature on that one.

 

As for muscle excersises... well, unless you can get your dog to do Kegel excersises, I can't think of anything that would help...

[lisa cosgrove]

for akdogdoc: is this incontinence an exception to the rule for spayed dogs or is it the common result of this procedure? (i've only had males.) i've often heard owners of females cite incontinence as a reason/excuse not to spay them and until now thought it was humbug.

[AK dog doc]

Actually, it's NOT that common. None of my own females have ever had it, and all of them have been spayed. It's also easily treated, so (in my view, anyway) it isn't that big a deal. Certainly if you stack it up against the drawbacks of not spaying (like mammary tumors, heat cycles, the risk - or occurance - of unwanted pregnancies, the life-threatening potential of uterine infections, ovarian cancer and uterine cancer, for instance) it seems like a pretty minor drawback. I don't have a percentage off the top of my head - I'll look one up today, if I have time at work - but it isn't very high. We don't have that many patients on DES, but we have TONS of spayed female dog patients. Myself, I'd rather face the small possibilty of having to spend $10 a month on medications which I have to give twice a week than I would even the CHANCE that my dog might die of sepsis or shock during a pyometra, which I could have prevented by spaying her. The guilt would be awful, even if the dog lived - to have made her pay the cost of a life-threatening illness I could easily have prevented, just to avoid some minor expense and inconvenience. But maybe I'm just overly-involved with my dogs - no life, you know! - so in the end everyone has to make up their own mind what risks they're willing to take on and ask their dogs to take on.

[jvw]

Okay, so now I'm very confused. I've been following this thread as I've been blessed with one of these incontinent females. She doesn't just leak. She puddles! Mainly when she's sleeping in my bed!!!

 

We started on PPA. Chewable tabs. Did that for about 7 days. She's a nervous dog to begin with and the meds seemed to make her extra jittery. So I stopped them (actually she refused to take them anymore). So then we went the holistic/homeopathic route. That worked great for three months! But now the problem is back.

 

So today I go back to my regular vet and ask if we can switch to DES. She reluctantly says yes but asked if I was aware of the problems. I say no. Well turns out she doesn't prescribe it anymore (nor does Michigan State) due to bone marrow suppression leading to cancer. YIKES!!! So long and short of it is she wants us to try the PPA again. Lower dose this time and switch to capsule rather than chew table. She thinks maybe Tyra was refusing to take it because it made her naseaus (I know I spelled it wrong).

 

Which is the lesser of two evils? I've heard that PPA can cause kidney problems and blood pressure problems. And you don't find the kidney problems until its way late. Now I'm hearing horror stories about the DES.

 

Are there any other options??

Jennifer

[AK dog doc]

PPA causes strokes in people, so it's been taken off the human market (it used to be the active ingredient in Dexatrim). In my hands, PPA does not work as well as DES; fewer dogs respond to it, and of those who do, some respond only temporarily. But maybe that's just been my particular patient load. None of them have so far had strokes or any cardiovascular problems, but a fair number have had a recurrence of incontinence (or a failure to respond in the first place). Some of them have also been jittery and/or hyper while on it or had other behavioral changes (including appetite suppression, which is presumably why it was in Dexatrim in the first place).

 

High-dose estrogen CAN cause bone marrow suppression. As I mentioned, I've never had any problem with this in any of my patients on DES, presumably in part because we don't dose it that high (someone mentioned 25 mg tabs; we go WAY below that dose). This does not mean it can't happen - just that, in my clinical practice, I have not seen it. Typically, the problem with bone marrow suppression and high dose estrogens is not cancer, it's that the bone marrow shuts down and never makes cells of any kind again. This, naturally, would be bad.

 

As far as low dose estrogens, as I say, I've never seen any detectable problems with my patients on this regimen. Hopefully I won't ever. I'd have to pull charts to see if any of them had any type of cancer (though I don't recall any that I know of for sure that had cancer AND were on DES). However, I DO know for sure that several of them would be dead already if we hadn't controlled their incontinence, because the owners would have euthanised them (Alaska isn't really a place where your average pet can really be a full-time outdoor dog unless it's a husky or a malamute, and even then it needs special handling and shelter.) You can certainly monitor white and red blood cell counts in dogs with only a few drops of blood, if you have concerns about it. Cancer is the leading cause of death in older dogs if you consider all types together. Therefore, even if one of my patients WAS on DES and DID get cancer, in an individual case I'd be hard-pressed to determine if DES had anything to do with it.

 

Your vet is being cautious on your dog's behalf, and that's a good thing. I try to do the same for my patients. However, real life is that diapers are not the best option for dogs in general (all that fur...) and if an owner can't live with a dog's incontinence, then what are the options? Make it an outdoor pet that gets diaper rash from wetting on itself, or euthanise it. So, given a choice between a *possibilty* of cancer down the road and a *certainty* of death today, generally speaking I'd opt for avoiding the certainty of death today. All medications have potential side effects, and all courses of treatment have consequences, including the course of doing nothing. At some point you have to make a choice about what consequences you most prefer. For me - and I'm saying this is ME, and not that everyone else should do the same - living with dog urine in my bed all the time is not an option. Nor is diapering my dog, not because of the inconveneince, but because I don't think it works that well to control leaks, and because of the diaper rash issues to the skin (and believe me, these can be horrendous.) This does not even consider the internal rashing they can have from urine pooling. Constant bathing creates its own problems, and in AK in the winter time is well beyond impractical. That leaves me with two options: medication or euthanasia. Guess which one I'm gong to pick? My success rate with DES is relatively high. My success with PPA is lower. That means I'd be picking DES first.

 

There's the ideal standard of medical care, to which we adhere as closely as possible. But there's also what occurs in the real world, and sometimes that's really quite different from what happens in a University setting. In the real world, we sometimes have to do what's practical instead of what's ideal; that's just the way it is. Sometimes the best you can do is to make the most informed decision you can and then live with it.

 

As far as other options, so far I've not used anything that works as well as DES. I've wondered about (but have not had occasion to try, nor do I know anyone else who has) the soy-based products being marketed for peri-menopausal women; I'm not sure on the pharmacology of the plant estrogens, and whether or not those are truly estrogens or if they merely have estrogen-like activity in the body. Moreover, I have no idea if they would be more likely, less likely or equally likely to cause estrogen-related side effects, nor what the effective dose would be, not what dose (if any) bore risks. This is something for me to ask at the next CE meeting I attend, perhaps. Meanwhile, I'll just have to do the best I can with what I have to work with.

[jvw]

Thanks Doc.

 

I guess for now I'll just try the PPA since DES will be so difficult for me to get a hold of. I was told we'll know if it works right away. But I'll be out of town this week (without dogs!!) so I won't know until next week. And then we'll keep tweeking the dose lower.

 

BTW, my vet said the bone marrow suppression from DES has happened even at extremely low doses. I don't know where this info comes from. But I have a very good friend at Penn Vet School so I've kinda given him a little project to research for me!

 

Thanks again

Jennifer

[AK dog doc]

No doubt - but there's "has happened" and there's "likely to happen" - and at least in my hands, having never had it happen in over a decade, I'm not of the "likely to happen" school, at least not for the moment. However, I'd be very curious to hear what your pal from Penn has to say - let me know, will you?

[diane allen]

Just to clarify....the AK doc was right, of course....my DES is only 1 mg (the 25 mg is part of the Deramax formula for the bigger dog!). Whew.

 

Thanks for your thoughts on the spay thing - it all makes sense to me (though I admit, I'd never thought about less experienced folks making larger incision - of course they would!). Just an idea I thought I'd float. No puppies from this girl anyway. And I'd surely NOT spay just to prevent this occasionaly problem. And no science claimed!

 

BTW, we did the diaper thing for awhile - ugh. Really nasty awful for her! The best alternatives I found (while we were "between" medications) are crib pads - just about the size of a crate or where she sleeps on my bed! - and the newer "waterproof" dog beds, which have a cover much like the pad. Easily washed and dried, and much like a regular bed!

 

diane

[jvw]

Well my friend from Penn grilled one of his profs for me. His prof insisted that at the extrememly low doses used to control incontinence DES is perfectly safe. Went on to say that the choice to prescribe DES or PPA is usually based on the docs age or the age of thier mentors!! Old school sticks with DES. New school goes with PPA. So I got no new concrete info from studies or the like!

 

I have been out of town and my friend has had Tyra. He was supposed to give half of a 75 mg capsule every night 1 hour before bed or if she was going to be hanging out on the couch. He managed to give her it at first. But he missed two nights in a row. Still it wasn't until the third day she had an accident. And actually then she had two. Now that I'm home I'll be able to monitor it better and see how low I can get the dosage. She doesn't seem to be displaying the agitation this time. But maybe that's because she's sleeping soon after she gets it.

 

Jennifer

[SoloRiver]

Who's your friend from Penn?

 

-- Melanie, also at Penn

[AK dog doc]

For me, at least, it's less about old-school/new-school than what works best in my experience. (And TRUST me that Dr. Deb - who taught us about estrogen-responsive incontinence in school - would be horrified and insulted to be thought of as old-ANYTHING! ) I just tend to prefer DES because I've had greater success with it and (so far) no unwanted side effects. If something better comes along, I'll be trying it. I am familliar with the old-school effect since I work with 3 other doc's all old enough to be my father - but of those three, only one is what I'd really call "old-school" - one is quite flexible in his approach and willingly tries new things (and equally willingly abandons them if they don't work as well as the old way, no matter what the University says), and the third is sort of in-between. I'm not sure if that's an age thing or if that's individual, since two of them were classmates and turned out differently. I hope I'll remain flexible with my medical approach as I age, but I may have to rely on you all here to poke me if I get all stodgy and hidebound.

[urge to herd]

My Samantha has been on pretty large doses of PPA for a few years, 110 mg 2x/day. She's been very restless, so I decided to experiment with some cranberry extract. I started giving her 300 mg cranberry extract 2x/day for a week, then reduced the PPA by a third. No leakage for a week, so I'm reducing the PPA by another third starting today, and we'll see what happens. The cranberry extract is continuing.

 

I'll post next week and let you guys know what's happening with her by then. Her restlessness and panting is already a lot better.

 

Ruth n The Border Trio

[Deanna in OR]

Our old Beardie-Golden mix, Maile, had this problem from time to time when she was younger. She mostly just would urinate in her sleep, so we knew it wasn't a behaviorable problem. A couple of times she was diagnosed with a urinary tract infection, but not everytime it started happening again.

 

One data point was that Maile always drank a LOT of water.

 

Later in life, Maile was diagnosed with diabetes. We maintained her on insulin for the last 2-1/2 years of her life (she died of a stroke at age 13.5). After she started on insulin, she never had an incontinence problem again, even though she became very arthritic and had a hard time getting around the last few months of her life. I always wondered if she wasn't somehow pre-diabetic and that contributed to her incontinence problem earlier in life, perhaps related to how much water she always drank.

 

by the way, she was spayed before 1 year of age.

 

If I had a dog with this problem, who also drank a lot of water, I would ask my vet about diabetes.

 

Deanna in OR