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Adjunctive Perioperative Vaginal Estrogen After Prolapse Repair

Rates of prolapse recurrence following native tissue surgical vaginal prolapse repair at 12 months were not improved by adjunctive perioperative vaginal estrogen application, researchers report. “Although expert opinion aligns with many urogynecologists’ anecdotal recommendations for pre- and/or postoperative vaginal estrogen to be used empirically for menopausal women undergoing reconstructive surgery, there are few prior studies that directly examine local estrogen use and postoperative outcomes,” conclude the authors.

At 3 tertiary clinical sites in Texas, Alabama, and Rhode Island, postmenopausal women with bothersome anterior and apical vaginal prolapse who were interested in surgery were enrolled in the trial in 2016–20. After randomization to conjugated estrogen cream 1 g or placebo cream, the investigators looked at a primary outcome of the time to failure of prolapse repair by 12 months after surgery (anatomical/objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, subjective vaginal bulge symptoms, or repeated prolapse treatment).

“Of 206 postmenopausal women, 199 were randomized and 186 underwent surgery,” write the authors. “The mean (SD) age of participants was 65 (6.7) years. The primary outcome was not significantly different for women receiving vaginal estrogen vs placebo through 12 months: 12-month failure incidence of 19% (n = 20) for vaginal estrogen vs 9% (n = 10) for placebo (adjusted hazard ratio, 1.97 [95% CI, 0.92-4.22]), with the anatomic recurrence component being most common, rather than vaginal bulge symptoms or prolapse repeated treatment. Masked surgeon assessment of vaginal tissue quality and estrogenization was significantly better in the vaginal estrogen group at the time of the operation. In the subset of participants with at least moderately bothersome vaginal atrophy symptoms at baseline (n = 109), the vaginal atrophy score for most bothersome symptom was significantly better at 12 months with vaginal estrogen.”

Editorial: “Surgeons should reconsider the modified Manchester procedure as a uterine-conserving surgical procedure for mild uterovaginal prolapse,” an editorialist writes. “Vaginal estrogen has many beneficial effects on the vaginal epithelium and patient symptoms, but surgeons should not prescribe vaginal estrogen with the expectation that it will improve surgical success.”

Source: JAMA