Priority 9 from the Pessary use for Prolapse PSP

UNCERTAINTY: When should oestrogen cream be used with a pessary? (JLA PSP Priority 9)
Overall ranking 9
JLA question ID 0054/9
Explanatory note There is a wide variation in practice across the world in relation to the use of oestrogen cream with pessaries either as routine or only when indicated by the vaginal condition. This priority could be added to future trials involving pessary use for prolapse.  Examples: Does use of oestrogen creams with pessaries increases satisfaction and persistence, or decreases adverse events? Do topical estrogen improve the vaginal sensation when using pessaries? Should an oestrogen cream be used as routine, or only with atrophic changes?

None identified

Health Research Classification System category Renal and urogenital
Extra information provided by this PSP
Original uncertainty examples

The use of topical vaginal oestrogen (in the absence of any contraindications) in postmenopausal women and women with vaginal atrophy may be helpful in reducing pessary complications and is commonly prescribed, however, high level evidence for its use is lacking.  ~  
This review did not find any clear evidence to suggest whether oestrogens work. However, as they are often used, especially with pessaries or before and after prolapse surgery, research is needed to identify any benefits or risks.  ~  The consideration of vaginal estrogen supplementation to lengthen pessary use among postmenopausal women electing to use a pessary as the treatment modality for prolapse and/or urinary incontinence.  ~  To assess conclusively whether vaginal estrogen enhances comfort and reduces complications of support pessaries for prolapse.  ~  Should all post menopausal women use topical oestrogen while using pessarys?  ~  Should an oestrogen cream be used as routine, or only with atrophic changes?  ~  Is it recommended to always have the patient use premarin prior to having a pessary fitted?  ~  Should oestrogen creams always be used on a several times per week basis when pessaries are fitted. I know some consultants who state that this should be the case, but I now other consultants who do not prescribe it when they fit a pessary ?

Submitted by 12 x healthcare professionals, 4 x literature, 1 x both
PSP information
PSP unique ID 0054
PSP name Pessary use for Prolapse
Total number of uncertainties identified by this PSP. 66  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 8 September 2017