Vaginal oestrogen around prolapse surgery: better symptoms, same anatomy

Surgeons have prescribed vaginal oestrogen around prolapse repair for years on the reasoning that better-oestrogenised tissue holds a suture better. The reasoning is plausible and the evidence has not supported it. A trial published in BJOG on 28 August tested it again with a different primary outcome, and the answer depends on what you decide the operation is for [s1].

Two trials, two questions

The 2023 comparison is the necessary background. A US randomised superiority trial at three tertiary sites in Texas, Alabama and Rhode Island enrolled 206 postmenopausal women with bothersome anterior and apical prolapse between December 2016 and February 2020; 199 were randomised and 186 had surgery [s2]. They received 1 g of conjugated oestrogen cream (0.625 mg/g) or placebo nightly for two weeks, then twice weekly for at least five weeks preoperatively, continuing twice weekly for 12 months after vaginal hysterectomy where relevant and standardised apical fixation [s2].

Its primary outcome was time to failure of the repair by 12 months, defined by anatomical prolapse beyond the hymen or apical descent of more than a third of vaginal length, subjective bulge symptoms, or repeat prolapse treatment [s2]. It found no benefit: 12-month failure incidence 19% (n = 20) with oestrogen versus 9% (n = 10) with placebo, adjusted hazard ratio 1.97 (95% CI, 0.92–4.22), driven mostly by the anatomic component [s2]. Masked surgeon assessment of vaginal tissue quality and oestrogenisation was significantly better in the oestrogen group at operation, and in the 109 participants with at least moderately bothersome atrophy symptoms at baseline, the atrophy score for the most bothersome symptom was better at 12 months [s2]. The conclusion was blunt: adjunctive perioperative vaginal oestrogen did not improve surgical success rates [s2].

The Dutch trial asked a different primary question of a similar intervention.

The new trial

It was a double-blind, randomised, placebo-controlled trial with 12-month follow-up across 22 hospitals in the Netherlands, enrolling postmenopausal women with POP-Q stage 2 or greater scheduled for primary native-tissue prolapse repair [s1]. Women were randomised 1:1 to vaginal oestriol cream (1 mg/g) or identical placebo, started four to six weeks preoperatively and continued to 12 months postoperatively on twice-weekly maintenance [s1].

The primary outcome was subjective: improvement in prolapse symptoms at 12 months, defined as "much" or "very much" improved on the Patient Global Impression of Improvement scale [s1]. In total 293 women participated and 57 dropped out [s1].

At 12 months, 92% of the oestrogen group versus 80% of the placebo group reported improvement on that scale (P = 0.02) [s1]. Pelvic-floor-related quality of life was better in the oestrogen group (median PFDI-20 score 17 vs 25; P = 0.03), and fewer women reported discomfort or pain on the EQ-5D-5L (61% vs 77%; P = 0.04) [s1]. Anatomical outcomes, composite surgical success, sexual function and reintervention rates did not differ between groups [s1]. The authors also report that the cream was easy to use and that 80% of participants would use it for a year if it provided meaningful health benefit [s1].

Reconciling them

The two trials do not contradict each other. Both find no effect on anatomy or on surgical success [s1][s2]. Both find symptom-level benefit — the US trial in the prespecified atrophy subgroup, the Dutch trial as its primary endpoint [s1][s2]. What differs is which of those the trial was designed to detect, and therefore which one gets reported as the headline.

That is not a trivial distinction. A treatment that reliably improves how women feel and reliably fails to improve how the repair holds is a legitimate adjunct, but it should be offered as the former and not sold as the latter. Vaginal oestrogen has well-established effects on genitourinary symptoms of menopause; a trial in surgical patients that finds symptom improvement is partly re-observing that.

Three limits sit on the Dutch result. The primary outcome is unblinded to the participant in the sense that matters — a woman using a cream may notice its local effects on dryness and comfort even under an identical-appearing placebo, and the Patient Global Impression of Improvement asks her to summarise everything at once. Fifty-seven dropouts out of 293 is a fifth of the cohort [s1]. And the reported outcomes are all at 12 months; prolapse recurrence is a multi-year problem, and the 2023 trial's anatomical failures were already accumulating faster in the oestrogen arm at one year, without reaching significance [s2].

The authors' conclusion is appropriately scoped: the findings support discussing vaginal oestrogen as an adjunctive option in shared decision-making with postmenopausal women undergoing primary prolapse surgery [s1]. The trial was registered as NL-OMON55535 [s1].

Sources

• [s1] "Vaginal Oestrogen Therapy for Postmenopausal Women Undergoing Prolapse Surgery: A Multicentre Double-Blind Randomised Placebo-Controlled Clinical Trial," BJOG, 28 August 2026. https://doi.org/10.1111/1471-0528.70311
• [s2] "Perioperative Vaginal Estrogen as Adjunct to Native Tissue Vaginal Apical Prolapse Repair: A Randomized Clinical Trial," JAMA, 15 August 2023. https://doi.org/10.1001/jama.2023.12317