The objective of this study was to compare the effects of systemic and local estrogen treatment on collagen assembly and biomechanical properties of the vaginal wall. Ovariectomized nulliparous rats were treated with estradiol or conjugated equine estrogens (CEEs) either systemically, vaginal CEE, or vaginal placebo cream for 4 wk. Low-dose local CEE treatment resulted in increased vaginal epithelial thickness and significant vaginal growth without uterine hyperplasia. Furthermore, vaginal wall distensibility increased without compromise of maximal force at failure. Systemic estradiol resulted in modest increases in collagen type I with no change in collagen type III mRNA. Low-dose vaginal treatment, however, resulted in dramatic increases in both collagen subtypes whereas moderate and high dose local therapies were less effective. Consistent with the mRNA results, low-dose vaginal estrogen resulted in increased total and cross-linked collagen content. The inverse relationship between vaginal dose and collagen expression may be explained in part by progressive downregulation of estrogen receptor-alpha mRNA with increasing estrogen dose. We conclude that, in this menopausal rat model, local estrogen treatment increased total and cross-linked collagen content and markedly stimulated collagen mRNA expression in an inverse dose-effect relationship. High-dose vaginal estrogen resulted in downregulation of estrogen receptor-alpha and loss of estrogen-induced increases in vaginal collagen. These results may have important clinical implications regarding the use of local vaginal estrogen therapy and its role as an adjunctive treatment in women with loss of vaginal support.

Objective Reconstructive surgery for pelvic organ prolapse is plagued with high failure rates possibly due to impaired healing or regeneration of the vaginal wall. Here, we tested the hypothesis that postoperative administration of local estrogen, direct injection of mesenchymal stem cells (MSCs), or both lead to improved wound healing of the injured vagina in a menopausal rat model. Methods Ovariectomized rats underwent surgical injury to the posterior vaginal wall and were randomized to treatment with placebo (n = 41), estrogen cream (n = 47), direct injection of MSCs (n = 39), or both (n = 43). Results MSCs did not survive after injection and had no appreciable effects on healing of the vaginal wall. Acute postoperative administration of vaginal estrogen altered response of the vaginal wall to injury with decreased stiffness, decreased collagen content, and decreased expression of transcripts for matrix components in the stromal compartment. Conversely, vaginal estrogen resulted in marked proliferation of the epithelial layer and increased expression of genes related to epithelial barrier function and protease inhibition. Transcripts for genes involved in chronic inflammation and adaptive immunity were also downregulated in the estrogenized epithelium. Conclusions Collectively, these data indicate that, in contrast to the reported positive effects of preoperative estrogen on the uninjured vagina, acute administration of postoperative vaginal estrogen has adverse effects on the early phase of healing of the stromal layer. In contrast, postoperative estrogen plays a positive role in healing of the vaginal epithelium after injury.

published minimally important differences (MID) for utilities; thus, both would be considered preferred strategies. Multiple one-way sensitivity analyses confirmed robustness of results. The probability of having R1 preoperative event was lowest for No MBP (1%) vs. any MBPs [MgCit (40%), Fleets (70%), NaPhos (55%), and PEG (75%)]. The probability of having R1 intra-or postoperative complication was lowest with MgCit (6%) compared to No MBP (16%) and other MBPs [Fleets (12%), NaPhos (30%), and PEG (40%)]. Conclusion: The highest utilities were seen with No MBP and MgCit with the absolute difference less than the MID thus making both the preferred strategies. Not surprisingly, No MBP had by far the lowest incidence of preoperative events and complications while MgCit had the lowest intraor postoperative complications. Both had higher overall utility values compared to other MBP options. With similar overall utilities between these two, our model raises serious questions as to whether MBP is a necessary step prior to laparoscopic gynecologic surgery. However, if a surgeon prefers a bowel preparation, MgCit would be the preferred option.

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Objectives To explore the knowledge, attitudes, and beliefs related to pessary use in Spanish-speaking women along the US-Mexico border. Methods Spanish-speaking women with symptoms of vaginal bulge were recruited from the urogynecology/gynecology clinics at Texas Tech University Health Sciences Center El Paso to participate in moderated focus groups. Discussion topics included knowledge of prolapse/pessaries, pros/cons of pessaries, alternatives, and prolapse surgery. Audio-recorded group discussions were transcribed verbatim, and qualitative analysis completed by independent review using grounded theory methodology. Common themes were identified and then aggregated to form consensus concepts, agreed upon by the reviewers. Results Twenty-nine Spanish-speaking women participated in 6 focus group discussions. Approximately half of women reported little or no prior knowledge about pessaries. Three main themes were identified from analysis: knowledge/perceptions, misinformation/misconceptions, and surgery-related concerns. Concepts identified from common themes included limited knowledge of pessaries, confusing “pessary” with “mesh,” willingness to try pessaries in order to avoid surgery, desire to try pessary if it was recommended by physician, limited efficacy or complications of surgery, and mesh-related concerns. Interestingly, some women reported that pessaries appear to be a treatment more often offered in the United States rather than in Mexico. Conclusions Most participants showed a willingness to try a pessary for symptoms of pelvic organ prolapse in an effort to avoid surgery, despite expressing limited knowledge about this treatment. Physician recommendations and risks of pessary use influence their likelihood of trying a pessary. These concepts serve as focus points for effective pessary counseling to help improve education and informed decision making in this patient population.