Causes Of Menopausal Pelvic Organ Prolapse
In numerous studies, menopause has been associated with the development of prolapse. The lack of estrogen causes thinning of the vagina and is thought to reduce the strength of the connective tissue supporting it.
Prolapse occurs when the tissues that support the pelvic organs are stretched and damaged. When this occurs, the organ that they support may drop down and press against the wall of the vagina. This causes a bulge in the vagina that will sometimes protrude through the vagina opening.
Initial prolapse can be due to stress from vaginal childbirth that later becomes evident after menopause with further atrophy of the tissue.
Additionally, the thinning and the lack of vaginal moisture associated with menopause can also cause problems with sexual function. The vaginal tissue becomes frail and less supple, and stretching from intercourse can be very irritating or even painful at times.
Local Estrogen In The Treatment Of Lower Urinary Tract Symptoms
A systematic review of 44 individual clinical studies from 2014 concluded that all available vaginal estrogen preparations reduce LUTS, including urinary urgency, frequency, lower urinary tract pain, urgency urinary incontinence and voiding dysfunction . Furthermore, some studies reported that local estrogen treatment improved the overall, subjective, objective and urodynamic variables in UI and overactive bladder also the mid-urethral closure pressure seemed greatest in patients treated with estrogens compared with pelvic floor exercises or electro-stimulation .
Local Estrogen In The Treatment Of Vvs
In postmenopausal women with vaginal dryness, itching, pain or burning, meta-analyses of randomized controlled trials concluded that vaginal estrogen cream use reduced symptoms in the majority of women, but only few women used them beyond 6 months . A systematic review, published in 2014, concluded that all commercially available vaginal estrogens effectively relieve common vulvovaginal atrophy-related complaints and have additional utility in patients with urinary urgency, frequency or nocturia, stress urinary incontinence and UUI, and recurrent UTIs . However, a recent large RCT concluded that neither the vaginal estradiol tablet nor the over-the-counter vaginal moisturizer provided additional benefit over placebo in reducing postmenopausal VVS .
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Influence Of Hrt On Ui
There are major discrepancies regarding the role of exogenous systemic estrogen administration for UI in the existing literature, and available clinical trials report conflicting results. On the one hand, subjective improvement of UI could be demonstrated in a few studies, but several clinical trials and reviews could not demonstrate any efficacyquite the contraryof estrogen therapy for treatment of UI . However, these results have to be interpreted with caution as different therapeutic interventions were used in terms of the type of estrogen, dose, route of administration and duration of therapy.
Selective Estrogen Receptor Modulators In The Treatment Of Oab
Regarding SERMs and OAB, Schiavi et al. assessed the effectiveness of Ospemifene in the improvement of the urgency component in women with MUI who underwent mid-urethral sling surgery. After surgical intervention, 38/81 patients received Ospemifene , and a significant difference was observed regarding mean number of voids, urgent micturition episodes/24 h, UUI, nocturia events and OAB-QoL symptoms. The authors concluded that Ospemifene is an effective therapy after MUSs in women with MUI, improving urgency symptoms and quality of life . Another study, also published by Schiavi et al., demonstrated that Ospemifene is also an effective therapy for postmenopausal women with VVA affected by OAB, improving sexual function and quality of life .
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Menopause & Pelvic Organ Prolapse At A Glance
- Changes in a womans pelvic floor function often accompany menopause. Weakening of the pelvic support structures can lead to pelvic organ prolapse, in which one or more organs of the pelvic area drops out of place.
- While there are many causes of pelvic organ prolapse , the lack of estrogen during menopause thins the support structures and tissue that hold pelvic organs in place, causing them to fall.
What Are The Next Steps
No matter the reason, frequent urination doesnt have to take over your life. Answers are only an appointment away.
Because once you know whats causing your frequent urination, youre that much closer to a peaceful nights sleep, uninterrupted jog around the lake or worry-free time doing whatever you like on your own terms.
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What Ovestin Cream Is Used For
Ovestin Cream is a Hormone Replacement Therapy . It contains the female hormone estriol . Ovestin is used in postmenopausal women with at least 12 months since their last natural period. Ovestin is used for relief of symptoms occurring after menopause. During menopause, the amount of oestrogens produced by a woman’s body gradually drops. If the ovaries are removed surgically before menopause, the decrease in oestrogen production occurs very abruptly. The shortage of oestrogens during menopause may cause the vaginal wall to become thin and dry. As a result, sexual intercourse may become painful and vaginal itching and infections may occur. Oestrogen deficiency may also lead to symptoms like urinary incontinence and recurrent cystitis. Ovestin alleviates these symptoms after menopause. It may take several days or even weeks before you notice an improvement. You will only be prescribed Ovestin if your symptoms seriously hinder your daily life. In addition to the above uses, Ovestin Cream may also be prescribed to improve wound healing in postmenopausal women undergoing vaginal surgery or help assess cervical smears taken from postmenopausal women. After insertion into the vagina, estriol is slowly released and absorbed into the surrounding area and into the bloodstream.
A doctor’s prescription is required to obtain this medicine.
This medicine is not expected to affect your ability to drive a car or operate machinery.
Continue Learning About Female Reproductive System Disorders
Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.
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We Hope To Change This Story
An ongoing clinical trial is examining the effectiveness of vaginal estrogen a supplemental, nonsurgical therapy to reduce symptom recurrence and spare more women the risks and financial implications of revisional surgeries.
For an appointment, please call Dr. Rahn at to discuss treatments.
Vaginal estrogen, when used prior to surgery, improved the resilience of the connective tissue in the pelvic floor.
David Rahn, M.D.
Vaginal Maturity Index Assessment
Cytological evaluation was performed using vaginal smears collected from the vaginal lateral wall and evaluated in our pathology department. The cytotechnologist estimated the proportion of parabasal, intermediate, and superficial cells, summing to 100, in the sample. All examinations were interpreted by the same blinded cytopathologist.
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Immunohistochemistry For Hormone Receptor
Tissues were paraffin-embedded and subjected to immunohistochemical staining. The sections were deparaffinized and rehydrated by rinsing in purified water and treated with 3% H2O2 for 15 min at room temperature. After rinsing three times with purified water, they were heated in an autoclave for 1 h with 10 mM citrate buffer and then incubated with primary antibodies. The estrogen receptor – , estrogen receptor – , progesterone receptor , and androgen receptor antibodies were diluted to a concentration of 1:50. After the appropriate secondary IgG antibody was applied, the sections were incubated with DAB and counterstained with haematoxylin . Finally, the sections were dehydrated in a graded series of ethanol, cleared with xylene, mounted in HISTOMOUNT , and evaluated by light microscopy after receiving cover slips. The proportion of stained cells and the extent of the staining were used as immunoreactive score scale for evaluation by a blinded, independent pathologist. The percentage of positive cells was assigned a score from 0 , 1 , 2 , 3 , or 4 .
Vaginal Estrogen Ring Helps Relieve Overactive Bladder
Up to 40% of postmenopausal women have overactive bladder an urgent and frequent need to urinate, sometimes resulting in incontinence. The most common drug treatment is oxybutynin , which is an anticholinergic medication. That means it blocks the neurotransmitter acetylcholine, relaxing the bladder and decreasing the need to urinate. But anticholinergics can cause dry mouth and constipation, side effects that prompt many women with overactive bladder to stop taking the medication. Now, a study in Menopause: The Journal of the North American Menopause Society finds there’s an equally effective alternative that lacks those side effects an ultra-low-dose estradiol vaginal ring . Vaginal estrogen cream can help manage overactive bladder symptoms, but creams can be messy and must be reapplied several times a week. The ring is worn continuously and can stay in place for three months.
The study. The study included 59 postmenopausal women with overactive bladder, defined as urinating 10 or more times in 24 hours. Thirty-one were randomly assigned to take oxybutynin 28 received the vaginal ring. The women recorded their urination times during two 72-hour periods, once at the start of the 12-week study and again at the end. They also filled out questionnaires on the distress caused by their symptoms and their overall quality of life.
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What Follow Up Is Required In Women Who Have Pessary To Treat Pelvic Organ Prolapse
All women with a long term pessary require regular follow up to ensure that they are not developing complications or problems related to the pessary. Regular checks are performed by a doctor every 4 to 6 months with removal and cleaning of the pessary and inspection of the vaginal tissues before the pessary is replaced. The interval between pessary checks can be extended by the doctor depending on the individual patient and the healthiness of the tissues at the time of the pessary check up.
Application Of A Simple Cream Might Reduce Recurrence Of Pelvic Floor Dysfunction Symptoms
Many women experience overactive bladder or urinary incontinence after childbirth or around the onset of menopause. Additionally, many women are also diagnosed with pelvic organ prolapse, a condition under the umbrella term of pelvic floor dysfunction.
Pelvic organ prolapse occurs when weakness in the vaginal wall allows organs such as the bladder, uterus, or rectum to bulge into the vaginal canal, causing:
- Heaviness, bulging pressure, pain in the pelvic area
- Inability to control the bladder or bowels
- Reduced quality of life
Traditionally, pelvic organ prolapse has been treated with surgery. However, according to the National Center for Biotechnology, common surgical repairs are ineffective for nearly 20 percent of patients, resulting in the need for second surgeries to fully resolve their symptoms. Despite these alarming numbers, U.S. doctors continue to perform approximately 300,000 of these surgeries a year.
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Summary Of Findings Regarding Local Oestrogen Treatment For Vaginal Atrophy
Studies comparing vaginal oestrogen treatment to placebo were consistent in reporting more beneficial effects on symptoms and signs of VA, vaginal maturation and vaginal pH after oestrogen treatment. Regarding most subjective and objective outcome measures no obvious differences between the different application methods were found. Comparison between oestrogen and non-hormonal treatment showed no differences in outcome as far as symptoms and vaginal pH. Signs at physical examination seemed to improve more with vaginal oestrogen treatment . No obvious differences were identified in the comparison of different doses of vaginal oestrogen with the exception of two studies showing a significant decrease in vaginal dryness in favor of a higher dose of oestrogen . Combination therapy seemed to have more beneficial effects regarding symptoms and signs of VA, vaginal cytology and pH as compared to only oestrogens .
Side Effects Of Vaginal Pessaries
Vaginal pessaries can occasionally cause:
- unpleasant smelling vaginal discharge, which could be a sign of a bacterial infection in the vagina
- some irritation and sores inside your vagina, and possibly bleeding
- stress incontinence, where you pass a small amount of urine when you cough, sneeze or exercise
- interference with sex
These side effects can usually be treated.
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Treatments For Menopausal Pelvic Organ Prolapse
Since lack of estrogen is the primary cause of menopausal pelvic organ prolapse, treatment in postmenopausal women involves hormone therapy . These can help restore the vagina to premenopausal condition and may help to strengthen the vaginal structures supporting the pelvic floor. The most common HT is low-dose vaginal estrogen replacement, utilizing creams, tablets or vaginal rings.
For advanced conditions of pelvic floor prolapse, your doctor may prescribe a pessary. A pessary is a device that, when placed into the vagina, holds varying organs in place. Normally, the patient is the one to clean the pessary to avoid infection however some pessaries must be taken out by medical professionals for cleaning.
In severe cases, surgical techniques to restructure support for the prolapsed organ are necessary. Usually performed transvaginally, the surgeon will secure the falling vaginal walls, bladder, urethra or other organ in its proper position.
While the use of mesh for pelvic organ prolapse has come under sharp scrutiny in recent years by both the medical community and consumers experiencing long-term side effects, the use of mesh for urinary incontinence is safe and commonly practiced.
Why Does Your Estrogen Level Matter
Estrogen is a hormone. Although present in the body in small amounts, hormones have big roles in maintaining your health.
Estrogen is commonly associated with the female body. Men also produce estrogen, but women produce it in higher levels.
The hormone estrogen:
- is responsible for the sexual development of girls when they reach puberty
- controls the growth of the uterine lining during the menstrual cycle and at the beginning of a pregnancy
- causes breast changes in teenagers and women who are pregnant
- is involved in bone and cholesterol metabolism
- regulates food intake, body weight, glucose metabolism, and insulin sensitivity
Girls who havent reached puberty and women approaching menopause are most likely to experience low estrogen. Still, women of all ages can develop low estrogen.
Common symptoms of low estrogen include:
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Are There Any Complications Of Using A Pessary Long Term
Potential complications of long-term vaginal pessary use to treat pelvic organ prolapse include:
- Ulcers can occur in the vagina due to the pessary which can be prevented by use of vaginal oestrogen
- Vaginal bleeding usually mild
- Treated by temporary removal of the pessary and use of antibiotics and vaginal oestrogen
The potential problems from having a vaginal pessary are minimal if the appropriate precautions are taken and ongoing review and check ups are performed.
Dr. Karen McKertich
The Pattern Of Incontinence Is Often Mixed
Symptoms of overactive bladder include frequency and nocturia . Some women also feel they need to pass urine, having only just done so due to over activity of the bladder muscle.
Recurrent urinary tract infections
UTIs can affect women of all ages, but this problem increases with age as a result of estrogen deficiency.
Management of urinary problems
Local estrogen
Local estrogen replacement therapy has been shown to alleviate urgency, urge incontinence, frequency, nocturia, dysuria and also to reduce urine infections.
Genuine Stress Incontinence would not appear to be helped by estrogen alone, but it does seem to improve the action of other treatments currently used.
The newer treatments including Ospemifene, DHEA and laser therapy may all have a beneficial effect on bladder problems.
Pelvic floor exercises
These can strengthen the pelvic floor reducing the risk of uterovaginal prolapse. Many women have learnt these techniques from childbirth, but it is well worth revisiting them.
Pelvic-floor physiotherapists are specialists in this field and are able to fully assess and monitor a womans pelvic floor function and teach appropriate techniques to strengthen it and retrain the bladder. They often use devices to help women perform appropriate exercises, such as weighted vaginal cones, or vaginal trainers. Your practice nurse or GP should be able to refer you to a specialist pelvic floor physiotherapist.
Surgery
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Other Therapy For Prolapsed Bladder
Physical therapy such as electrical stimulation and biofeedback may be used for a prolapsed bladder to help strengthen the muscles in the pelvis.
- Electrical stimulation: A doctor can apply a probe to targeted muscles within the vagina or on the pelvic floor. The probe is attached to a device that measures and delivers small electrical currents that contract the muscles. These contractions help strengthen the muscles. A less intrusive type of electrical stimulation is available that magnetically stimulates the pudendal nerve from outside the body. This activates the muscles of the pelvic floor and may help treat incontinence.
- Biofeedback: A sensor is used to monitor muscle activity in the vagina and on the pelvic floor. The doctor can recommend exercises that can strengthen these muscles. These exercises may help strengthen the muscles to reverse or relieve some symptoms related to a prolapsed bladder. The sensor can monitor the muscular contractions during the exercises, and the doctor may be able to determine if the targeted muscles would benefit from the exercises.
Estradiol And Estrone Assays And Assessment Of Adherence
To determine systemic absorption of estrogen during the 6-week preoperative period of cream application, serum levels of estrone and 17-estradiol were assessed at baseline and on the morning of surgery using a highly sensitive liquid chromatography-tandem mass spectrometry assay. The chromatographic separation was performed on 150 × 2.0 mm Phenomenex Synergi 4Max-RP columns as previously described . The assay had previously been validated and, for E1, critical analyte concentration was 1.2 pg/mL with a detection limit of 3.5 pg/mL and a practical detection range of 3.5600 pg/mL functional assay sensitivity for E1 was less than 11.9 pg/mL. The intraassay coefficient of variation for E1 ranged from 9% at a concentration of 11.5 pg/mL to 2% at 365 pg/mL, whereas interassay CVs were between 12% and 4% . For E2, the critical concentration was 1.7 pg/mL with a lower detection limit of 2.8 pg/mL the detection range was 2.8600 pg/mL, and the functional sensitivity was 6.3 pg/mL. The intraassay CV ranged from 15% at a concentration of 6.6 pg/mL to 2% at 357 pg/mL interassay CVs were between 20% and 5% . Hysterectomy specimens were examined by a blinded pathologist for endometrial and myometrial thickness and pathology.
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