Guidance from the American College of Obstetricians and Gynecologists (ACOG), in collaboration with the American Urogynecologic Society (AUS), provides detailed recommendations on the management of complications associated with mesh used for stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Management of mesh-related complications in pelvic floor surgery involves a spectrum of approaches that include observation, physical therapy, medications, and surgical intervention. For symptomatic women, a trial of vaginal estrogen (no specific formulation or strengths discussed) may be considered for small exposures (less than 0.5 cm), with a trial period of 6-12 weeks. Although topical estrogen may improve or resolve mesh exposure, supporting evidence is limited. A multicenter study highlighted that 60% of women with mesh complications required two or more interventions, with the first intervention being surgical in about half of the cases. Such procedures are complex and should be handled with caution, emphasizing the importance of referral to surgeons familiar with these repairs if the original procedures or subsequent management issues are beyond the operating surgeon's experience. [1]
Vaginal mesh exposure following a midurethral sling procedure occurs in approximately 1-2% of cases. For asymptomatic patients with type 1 mesh, expectant management, with or without the application of topical estrogen, may be appropriate, as some small case reports indicate that spontaneous reepithelialization is possible. Should topical estrogen fail, surgical options include excising the edges of the vaginal incision and reapproximating them for a tension-free closure, though few success rates are published for primary reclosure. The procedure is considered low-risk. In cases where both expectant management and primary reclosure fail, and if the patient wishes to preserve the sling, options like full-thickness autologous graft transposition or Martius graft transposition have been documented, although data to guide these decisions is sparse. If preservation methods are unsuccessful and the patient remains symptomatic, sling excision may be performed, albeit with a risk of recurrent stress urinary incontinence (SUI). Complete removal of the mesh is usually unnecessary. [1]
A 2023 randomized trial (IMPROVE) investigated the efficacy of perioperative vaginal estrogen as an adjunct to native tissue vaginal apical prolapse repair. Conducted across three United States tertiary clinical sites, the trial enrolled 206 postmenopausal women with symptomatic anterior and apical vaginal prolapse who were candidates for surgical repair. Participants were randomized in a 1:1 ratio to receive either conjugated estrogen cream (0.625 mg/g) or a visually identical placebo cream. The intervention was administered intravaginally nightly for two weeks, then twice weekly for at least five weeks preoperatively, continuing at the same frequency for 12 months postoperatively. Standardized surgical procedures were performed by masked surgeons; midurethral slings (MUS) were performed in 57% of both estrogen and placebo patients, while hysterectomies were performed in 82% and 85% of estrogen and placebo patients, respectively. The 12-month incidence of surgical failure was 19% in the vaginal estrogen group and 9% in the placebo group, with an adjusted hazard ratio (HR) of 1.97 (95% confidence interval [CI] 0.92 to 4.22). No statistically significant difference in surgical success was observed between treatment arms. Despite better intraoperative assessments of vaginal tissue quality in participants receiving estrogen, this did not translate into improved surgical outcomes. However, among participants with bothersome vaginal atrophy symptoms at baseline, those in the estrogen group demonstrated significantly greater improvement in atrophy-related symptoms (adjusted mean difference -0.87; 95% CI -1.67 to -0.07; p= 0.003). Urinary tract infections occurred at a similar frequency between groups, while increases in postoperative granulation tissue were more frequently observed in the estrogen group. These findings suggest that while perioperative vaginal estrogen enhanced vaginal tissue quality and alleviates atrophic symptoms, it did not reduce prolapse recurrence following native tissue transvaginal repair. [2]
A 2015 retrospective cohort study evaluated whether the preoperative use of vaginal estrogen influences the risk of mesh exposure following synthetic MUS placement. The investigation included 1,544 women who underwent MUS insertion in 2010. Preoperative estrogen use was determined based on filled prescriptions within 45 days before surgery or documented use in preoperative evaluations. Findings indicated that 16.1% (n= 248) of the cohort had used vaginal estrogen preoperatively, primarily in the form of estrogen cream (90.3%). Mesh exposure occurred in 2.4% (n= 37) of patients, with nearly half (n= 19) requiring surgical revision. Median time to mesh exposure diagnosis was 56 days postoperatively. Multivariate analysis demonstrated no statistically significant association between preoperative vaginal estrogen use and mesh exposure risk (odds ratio [OR] 0.79; 95% CI 0.26 to 2.38; p= 0.67). Additionally, other evaluated factors (e.g., smoking, menopausal status, diabetes) were not associated with mesh exposure. Despite inherent limitations of retrospective study design and sample size constraints, the findings suggest that preoperative vaginal estrogen use does not mitigate the risk of mesh exposure following MUS placement. [3]
A 2010 analysis of a 12-month, double-blind, randomized, parallel-therapy trial compared the cardiovascular and metabolic effects of medroxyprogesterone acetate (MPA) and conjugated equine estrogen (CEE) as monotherapy in 33 premenopausal women undergoing hysterectomy with bilateral ovariectomy. Participants received either MPA 10 mg/day (n= 18) or CEE 0.6 mg/day (n= 15) starting immediately post-surgery. After 12 months, women assigned to CEE exhibited significantly greater increases in CRP (p= 0.01) and reductions in serum albumin (p<0.0005) versus those receiving MPA, suggesting a pro-inflammatory effect of estrogen therapy. The MPA group experienced significantly lower increases in BMI (p= 0.04), triglycerides (p= 0.003), and sex hormone-binding globulin (SHBG; p<0.0005), while CEE use was associated with higher HDL (p<0.0005) and total testosterone (p= 0.003) levels. Despite these differences, bioavailable testosterone levels, estimated using the free androgen index, remained similar between groups. Additionally, BMI and CRP demonstrated a positive correlation in the MPA group (p<0.005), an association that was absent in the CEE group. These findings indicate that MPA may exert a more favorable effect on inflammation, lipid metabolism, and body composition compared to CEE monotherapy in surgically menopausal women, warranting further research in larger controlled trials. [4]
A 2006 controlled trial (Table 1) evaluated the benefit and safety of a 28-day transdermal 17-beta estradiol regimen in postmenopausal women undergoing vaginal hysterectomy. 269 participants were divided into two groups: one receiving a transdermal estrogen hormone replacement therapy (TEHRT) regimen of 50 mcg/day 17-β estradiol for 14 days preoperatively and 14 days postoperatively, and a control group receiving vaginal estrogen hormone replacement therapy (VEHRT) in the form of 0.625 mg/day conjugated estrogen cream (Premarin) for 14 days preoperatively. Findings demonstrated significantly improved wound healing parameters in the TEHRT group, including reduced pain, swelling, vaginal discharge, and wound dehiscence (p<0.001). Postoperative infection markers, such as leukocyte count and fever incidence, were also lower in the TEHRT group (p<0.01). On follow-up, patients in the TEHRT group exhibited better anatomical outcomes, with a higher frequency of stage 0 apical prolapse (p <0.05) and greater total vaginal length preservation (p<0.05). The endometrial evaluation revealed a modest estrogenic effect in TEHRT recipients, with an increased frequency of an endometrial thickness between 2 and 4 mm (p<0.05); however, no cases of complex hyperplasia, atypical hyperplasia, or carcinoma were observed in either group. The findings suggest that a 28-day transdermal 17-β estradiol regimen offers superior postoperative recovery while maintaining an acceptable safety profile concerning endometrial health. [5]