Botulinum toxin in women’s health: An update
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.
References (43)
- et al.
Botulinum toxin type a injections into the trigone to treat idiopathic overactive bladder do not induce vesicoureteral reflux
J. Urol.
(2007) Comparison of effectiveness of detrusor, suburothelial and bladder base injections of botulinum toxin a for idiopathic detrusor overactivity
J. Urol.
(2007)- et al.
Prospective randomised controlled trial comparing trigone-sparing versus trigone-including intradetrusor injection of abobotulinumtoxinA for refractory idiopathic detrusor overactivity
Eur. Urol.
(2012) - et al.
OnabotulinumtoxinA 100 U significantly improves all idiopathic overactive bladder symptoms and quality of life in patients with overactive bladder and urinary incontinence: a randomised, double-blind, placebo-controlled trial
Eur. Urol.
(2013) - et al.
EMBARK study group. OnabotulinumtoxinA for the treatment of patients with overactive bladder and urinary incontinence: results of a phase 3, randomized, placebo controlled trial
J. Urol.
(2013) - et al.
Efficacy and safety of onabotulinumtoxinA for idiopathic overactive bladder: a double-blind, placebo controlled, randomized, dose ranging trial
J. Urol.
(2010) - et al.
Botulinum toxin type A versus amitriptyline for the treatment of chronic daily migraine
Clin Neurol Neurosur.
(2010) - et al.
A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines
J. Am. Acad. Dermatol.
(2002) - et al.
Botulinum toxin a and lower urinary tract dysfunction: pathophysiology and mechanisms of action
Toxins (Basel)
(2016) - et al.
2012 Update: guidelines for adult urinary incontinence collaborative consensus document for the Canadian Urological Association
Can. Urol. Assoc. J.
(2012)
Botulinum toxin injections for adults with overactive bladder syndrome
Cochrane Database Syst. Rev.
Anticholinergic drugs versus placebo for overactive bladder syndrome in adults
Cochrane Database Syst. Rev.
Which anticholinergic drug for overactive bladder symptoms in adults
Cochrane Database Syst. Rev.
Drug Safety Labeling. Botox (onabotulinumtoxinA) FDA
Bladder base/trigone injection is safe and as effective as bladder body injection of onabotulinumtoxinA for idiopathic detrusor overactivity refractory to antimuscarinics
Neurourol. Urodyn.
V.W. OnabotulinumtoxinA 100 U provides significant improvements in overactive bladder symptoms in patients with urinary incontinence regardless of the number of anticholinergic therapies used or reason for inadequate management of overactive bladder
Int. J. Clin. Pract.
Anticholinergic therapy vs. Onabotulinumtoxina for urgency urinary incontinence
N. Engl. J. Med.
the efficacy and safety of onabotulinumtoxina or solifenacin compared with placebo in solifenacin naïve patients with refractory overactive bladder: results from a multicenter, randomized, double-blind phase 3b trial
The Journal of Urology
Effectiveness of botulinum toxin injection in the treatment of de novo OAB symptoms following midurethral sling surgery
Int. Urogynecol. J.
Can botox improve night‐time overactive bladder symptoms in women?
Neurourol. Urodyn.
Medium- to long-term outcomes of botulinum toxin A for idiopathic overactive bladder
Ther. Adv. Urol.
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