• Although 14 studies met the inclusion criteria for this review, no studies addressed our comparisons of greatest interest, so we are uncertain about the effects of oestrogen therapy on pelvic organ prolapse in postmenopausal women.
• Further research is needed to assess the effects of oestrogen therapy, alone or in combination with other treatments, on pelvic organ prolapse in postmenopausal women.
What is pelvic organ prolapse?
Pelvic organ prolapse is when a woman's uterus (womb), bladder, or rectum moves down from its normal position into the vagina. It is a common condition, affecting 50% of women over 50 years old who have had at least one child. Between 6% and 12% of women who have had a hysterectomy (surgical removal of the uterus) will experience pelvic organ prolapse. Women who are older, who have had more children, and who are overweight are more likely to have pelvic organ prolapse. Women with pelvic organ prolapse may have the feeling of "something coming down" into the vagina, or other symptoms that can negatively affect their quality of life and body image, such as discomfort during sex or urinary problems.
What did we want to find out?
Many clinicians prescribe oestrogen therapy (a type of hormonal therapy) to treat pelvic organ prolapse, sometimes in combination with other treatments such as a pessary (a device inserted into the vagina to provide support) or surgery. However, the benefits of this approach are unclear. We wanted to find out whether using oestrogen therapy, either alone or together with other treatments, could improve the symptoms of pelvic organ prolapse in women after their menopause.
What did we do?
We searched for studies that investigated the effects of oestrogen therapy, either alone or in combination with other treatments such as pessaries or surgery, on postmenopausal women. We compared and summarised the results of these studies and rated our confidence in the results based on aspects such as methods and number of participants.
What did we find?
We found 14 studies involving a total of 1002 women. Ten studies recruited women with different severities of pelvic organ prolapse. There were differences across studies in terms of the location of pelvic organ prolapse, the number of children the women had had, whether the women had had a hysterectomy, and the type of oestrogen therapy being investigated.
Although we identified 14 eligible studies, no studies addressed our main comparisons of interest (oestrogen therapy alone compared with no treatment, compared with pelvic floor muscle exercises, compared with surgery, or compared with devices such as vaginal pessaries). Four studies evaluated oestrogen therapy alongside vaginal pessaries compared with vaginal pessaries alone, and 10 studies evaluated oestrogen therapy alongside surgery compared with surgery alone.
What are the limitations of the evidence?
The evidence is very uncertain because of concerns about the studies' methods. The women were often aware of the treatments they were receiving, which may have affected the results. Additionally, many studies included few women.
How up to date is this evidence?
The evidence is up to date to 20 June 2022.
There was insufficient evidence from RCTs to draw any solid conclusions on the benefits or harms of oestrogen therapy for managing POP symptoms in postmenopausal women. Topical oestrogen in conjunction with pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and topical oestrogen in conjunction with surgery was associated with reduced postoperative urinary tract infections compared with surgery alone; however, these findings should be interpreted with caution, as the studies that contributed data varied substantially in their design.
There is a need for larger studies on the effectiveness and cost-effectiveness of oestrogen therapy, used alone or in conjunction with pelvic floor muscle training, vaginal pessaries, or surgery, for the management of POP. These studies should measure outcomes in the medium and long term.
Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at least one child, and recognised risk factors are older age, higher number of births, and higher body mass index. This review assesses the effects of oestrogen therapy, alone or in combination with other treatments, on POP in postmenopausal women.
To assess the benefits and harms of local and systemic oestrogen therapy in the management of pelvic organ prolapse symptoms in postmenopausal women, and to summarise the principal findings of relevant economic evaluations.
We searched the Cochrane Incontinence Specialised Register (up to 20 June 2022), which includes CENTRAL, MEDLINE, two trials registers, and handsearching of journals and conference proceedings. We also checked the reference lists of relevant articles for additional studies.
We included randomised controlled trials (RCTs), quasi-RCTs, multi-arm RCTs, and cross-over RCTs that evaluated the effects of oestrogen therapy (alone or in combination with other treatments) versus placebo, no treatment, or other interventions in postmenopausal women with any grade of POP.
Two review authors independently extracted data from the included trials using prespecified outcome measures and a piloted extraction form. The same review authors independently assessed the risk of bias of eligible trials using Cochrane's risk of bias tool. Had data allowed, we would have created summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE.
We identified 14 studies including a total of 1002 women. In general, studies were at high risk of bias in terms of blinding of participants and personnel, and there were also some concerns about selective reporting. Owing to insufficient data for the outcomes of interest, we were unable to perform our planned subgroup analyses (systemic versus topical oestrogen, parous versus nulliparous women, women with versus without a uterus).
No studies assessed the effects of oestrogen therapy alone versus no treatment, placebo, pelvic floor muscle training, devices such as vaginal pessaries, or surgery. However, we did identify three studies that assessed oestrogen therapy in conjunction with vaginal pessaries versus vaginal pessaries alone and 11 studies that assessed oestrogen therapy in conjunction with surgery versus surgery alone.