Elsevier

Maturitas

Volume 119, January 2019, Pages 21-24
Maturitas

Botulinum toxin in women’s health: An update

https://doi.org/10.1016/j.maturitas.2018.10.005Get rights and content

Highlights

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    Botulinum toxin is generally a safe, effective treatment approved for symptoms of overactive bladder, chronic migraine and facial lines.

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    The safety and efficacy has been well demonstrated but there are very few head-to-head studies comparing treatments.

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    Further research is needed directly comparing BoNT-A with other medical therapies.

Abstract

Botulinum toxin, from the bacteria Clostridium botulinum, acts by block the pre-synaptic release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis. There are several clinically available formulations, the most extensively studied being of onabotulinumtoxinA. This article outlines three of the common clinical applications of onabotulinumtoxinA relevant to women’s health: the management of symptoms of overactive bladder, chronic migraine and facial lines. Its safety and efficacy have been well demonstrated but very few studies have directly compared treatments. Further research is needed directly comparing therapies to help guide treatment choices and predict success.

Introduction

Botulinum toxin is derived from the bacteria Clostridium botulinum. The primary action of the toxin is to block the pre-synaptic release of acetylcholine at the neuromuscular junction to result in temporary muscle paralysis. Secondary mechanisms of action involve inhibition of a range of other neurotransmitters and inflammatory cells [1].

Whilst there are several serotypes of botulinum toxin, serotypes A and B are the only ones in clinical use. There are also different formulations of the same serotype available in different countries. For example, the various formulations of serotype A include onabotulinumtoxinA, abobotulinumtoxinA and incobotulinumA. Doses between formulations are not comparable. As serotype A in the formulation of onabotulinumtoxinA (BoNT-A) is the most extensively studied and commonly used it is the focus of this report.

The medicinal uses of botulinum toxin are varied. This article outlines three common clinical applications relevant to women’s health in order to provide clinicians with general, succinct information to help guide management discussions and clinical decisions. The applications discussed include overactive bladder, chronic migraine and facial lines.

To evaluate the evidence in this area a systematic search was undertaken using the MEDLINE and Cochrane databases. Search terms included: “onabotulinumtoxinA”, “botox”, “overactive bladder”, “bladder dysfunction”, “urinary”, “incontinence” “migraine”, “facial lines”, “cosmetic” and “rhytides”. Results were limited to those published in English and further relevant studies were obtained from reference lists of included studies.

Section snippets

Bladder dysfunction

Overactive bladder (OAB) involves a collection of symptoms including urinary urgency, which may include incontinence, as well as urinary frequency and nocturia [2]. OAB affects approximately 13% of women, and almost half report urinary incontinence [2,3], which can significantly impair quality of life. This section outlines the use of botulinum toxin in the management of idiopathic OAB.

Management of OAB usually begins with non-pharmacological treatment including lifestyle modification.

Chronic Migraine

Chronic migraine affects approximately 2% of the population [24] and is defined as headaches present on 15 or more days per month, for more than three months, with migraines on at least eight of those days [25].

First-line pharmacotherapy in the treatment of chronic migraine involves the use of beta-blockers including propranolol, anti-depressants (eg amitriptyline) and anticonvulsants (eg topiramate or sodium valproate) [26]. BoNT-A was approved for use in chronic migraine by the US Food and

Facial lines

The muscle paralysis effect of botulinum toxin has facilitated its cosmetic use to reduce facial and neck lines associated with ageing. The most common aesthetic uses of botulinum toxin approved by the US FDA are glabellar lines (GL), or forehead frown lines, and lateral canthal lines, commonly known as crow’s feet (CFL).

Botulinum toxin A is the most commonly clinically used serotype of botulinum toxin and there are several commercially available formulations of serotype A. High-level

Conclusion

This article provides an overview of the three primary uses of botulinum toxin in women’s health. BoNT-A is generally a safe, effective treatment approved in many countries for symptoms of overactive bladder, chronic migraine and facial lines. Barriers to the use of BoNT-A include meeting the clinical criteria for approved use, access to specialist clinicians and the financial cost of treatment, which may be significant although subsidised to varying degrees depending on the use. Globally

Practice points

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    Botulinum toxin is effective in the treatment of overactive bladder, significantly reducing episodes of urinary frequency and incontinence.

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    The optimal dosing regimen is unclear. However, higher doses have not been shown to be more effective and are associated with increased risk of side effects including urinary retention.

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    Botulinum toxin is an effective treatment in the management of chronic migraine, reducing frequency and severity of headaches and improving quality of life.

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    The cosmetic uses

Research agenda

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    Head-to-head research directly comparing BoNT-A with other medical therapies for OAB, including symptom evaluation of symptoms other than incontinence such as frequency and nocturia.

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    Further research involving long-term follow-up in migraine management is needed to better identify the requirement, safety and efficacy of repeated dosing.

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    Head-to-head trials comparing BoNT-A with other migraine treatments are needed.

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    Cost-effectiveness of comparative therapies considering need for repeated dosing,

Contributors

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    Annabelle Brennan drafted and critically revised the manuscript.

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    Martha Hickey critically revised the manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

No funding was received for the preparation of this review.

Provenance and peer review

This article has undergone peer review.

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