title: Does vaginal estrogen treatment with support pessaries in vaginal prolapse reduce complications?
abstract: OBJECTIVE
  Pelvic organ prolapse is often co-existant with atrophy of the genital tract in older women who tend to prefer vaginal pessaries for prolapse. Vaginal estrogen therapy is used by some along with a support pessary for prolapse with no robust evidence to back this practice. We aimed to evaluate differences in complications of support pessaries for vaginal prolapse in postmenopausal women, with and without vaginal estrogen use.
  
  
  METHODS
  We prospectively assessed postmenopausal women attending the urogynaecology clinic for a pessary change. We asked them about the level of discomfort during pessary change (visual analogue scale for pain), discharge, bleeding and infection. Ethics approval was not required as this was a service evaluation project. Statistical analysis for relative risk was performed, including sub-group analysis for 'ring pessary' and 'non-ring group' (Shelf, Gellhorn, Shaatz).
  
  
  RESULTS
  Between July 2013 and December 2014, we assessed 120 postmenopausal women using support pessaries for prolapse. The mean age was 70 years; 45% of the patients used vaginal estrogen. There were no statistically significant differences in complications with or without vaginal estrogen use, although the trend was higher amongst non-users. The 'non-ring' sub-group not using vaginal estrogen had a higher risk of vaginal ulceration, bleeding and discharge.
  
  
  CONCLUSIONS
  Postmenopausal women may have lesser complications when using vaginal estrogen with a support pessary for prolapse, particularly with pessaries other than the ring. An adequately powered randomised controlled trial is needed to assess conclusively whether vaginal estrogen enhances comfort and reduces complications of support pessaries for prolapse.
authors.affiliation: Birmingham Women's NHS Foundation Trust, Birmingham, UK drsupriya73@yahoo.co.uk.
authors.forename: Supriya
authors.initials: S
authors.lastname: Bulchandani
authors.affiliation: Birmingham Women's NHS Foundation Trust, Birmingham, UK.
authors.forename: Philip
authors.initials: P
authors.lastname: Toozs-Hobson
authors.affiliation: School of Clinical and Experimental Medicine, University of Birmingham, Birmingham UK.
authors.forename: Tina
authors.initials: T
authors.lastname: Verghese
authors.affiliation: Birmingham Women's NHS Foundation Trust, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham UK.
authors.forename: Pallavi
authors.initials: P
authors.lastname: Latthe
mesh_terms: D000282:Administration, Intravaginal; D000368:Aged; D000369:Aged, 80 and over; D020878:Device Removal / Q000009:adverse effects; D004958:Estradiol / Q000008:administration & dosage*; D004967:Estrogens / Q000008:administration & dosage*; D005260:Female; D006801:Humans; D007239:Infections / Q000209:etiology; D008875:Middle Aged; D010146:Pain / Q000209:etiology / Q000517:prevention & control; D010570:Pessaries / Q000009:adverse effects*; D017698:Postmenopause; D011446:Prospective Studies; D014456:Ulcer / Q000209:etiology / Q000517:prevention & control*; D014592:Uterine Hemorrhage / Q000209:etiology / Q000517:prevention & control; D014596:Uterine Prolapse / Q000628:therapy*; D019522:Vaginal Discharge / Q000209:etiology / Q000517:prevention & control; D014623:Vaginal Diseases / Q000209:etiology / Q000517:prevention & control*
chemical_list: D004967:Estrogens; D004958:Estradiol
keywords: Postmenopausal women; prolapse; vaginal estrogen; vaginal pessary