Clear Urine Following Estradiol HRT Initiation

Case at a Glance

A 53-year-old female with rheumatoid arthritis and history of alcohol use disorder presents with sudden onset of clear, water-like urine following initiation of estradiol HRT cream. Patient expresses concern about potential renal or hepatic complications.

Patient's Story

The patient is a 53-year-old woman, 5'3" and 145 lbs, with a medical history significant for rheumatoid arthritis, depression, hyperlipidemia, and alcohol use disorder. She is currently on plaquenil for RA management, lexapro for depression, and statin therapy. She recently started topical estradiol cream for menopausal symptoms, particularly night sweats. She is scheduled for bladder sling surgery with pre-operative evaluation pending. The patient reports that for several days, her urine has appeared completely clear, resembling water. She denies any increase in fluid intake, pain, fever, or other urinary symptoms. She underwent a catheter-based bladder function test one week prior. The patient has a significant history of alcohol abuse and was hospitalized approximately one year ago for a bleeding duodenal ulcer. Recent endoscopic follow-up showed complete ulcer healing with no evidence of liver disease, confirmed by fibroscan.

Initial Assessment

Patient presents with acute onset of clear urine without associated symptoms. Vital signs stable. No fever, pain, or signs of systemic illness. Recent initiation of estradiol HRT and recent urological procedure noted as potential contributing factors.

The Diagnostic Journey

Differential diagnosis includes medication-induced effects (estradiol HRT), post-procedural changes following catheter testing, diabetes insipidus, early renal dysfunction, or hepatic insufficiency. Given the patient's history of alcohol use disorder, concern for occult liver or kidney disease warrants investigation despite recent normal hepatic studies.

Final Diagnosis

Pending urinalysis and comprehensive metabolic panel. Likely estradiol-induced alteration in urine concentration or post-procedural effect from recent catheter testing.

Treatment Plan

Observation with urinalysis and basic metabolic panel if symptoms persist beyond 48-72 hours. Consider discontinuation of estradiol cream if no other cause identified. Routine pre-operative laboratory studies will provide additional metabolic information.

Outcome and Follow-up

Patient advised to monitor symptoms and follow up with primary care physician if clear urine persists beyond several days. Pre-operative evaluation will include comprehensive laboratory studies that may provide additional diagnostic information.