Prolapse treatment has high failure rates, patients still report improved quality of life

April 24, 2018
Ben Schwartz

Ben Schwartz is Associate Editor, Contemporary OB/GYN.

Results of a recent extended study of prolapse surgery  showed that in 60% of women, two common procedures failed within 5 years, but patients still reported a higher quality of life than before the surgery. Plus: ACOG has released a revised Committee Opinion to emphasize the idea of the “fourth trimester” in an attempt to reduce maternal morbidity and mortality numbers. Also: A recent study suggests that entering menopause later in life may be associated with a small boost in memory performance years later.

Results of a recent extended study of prolapse surgery  showed that in 60% of women, two common procedures failed within 5 years. Nevertheless, more than half of those patients still reported better quality of life than before uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF).

Of the 285 women enrolled in the study, published in JAMA, 244 (86%) completed the extended trial. The participants came from the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) Trial, a 2 x 2 factorial trial that compared 2-year outcomes in women undergoing vaginal apical prolapse repair with midurethral sling for stress urinary incontinence. Enrollment in the original trial was from January 2008 to March 2011. During postoperative years 3 through 5, in-person evaluation at the clinical site and telephone interviews conducted by the central facility at the data coordinating center were performed annually. The primary outcome of the study was the time-to-event outcome of surgical failure up to 5 years after surgery.

ULS was used to treat 126 of the 244 women who completed the trial and 118 underwent SSLF. The rate of failure at 5 years in the SSLF group was 70.3% and in the ULS group it was 61.5%. A procedure was considered a failure if, after 5 years, the repaired tissue descended past the upper third of the vaginal canal. In addition, if a patient felt a bothersome bulge or sensation of prolapse, another surgery was necessary, or a removable pessary was necessary to relive her symptoms, the procedure also was considered a failure. Of the participants, 12% of ULS patients and 8% of SSLF patients were treated again with one of these options. The researchers also found no significant difference in outcomes when patients had several weeks of behavioral therapy and pelvic muscle floor training both before and after the surgery.

Quality of life for the patients significantly improved from before surgery to 5 years after in both groups. The ULS group and SSLF group had Pelvic Organ Prolapse Distress Inventory scores of −67.6 and −74.2, respectively; adjusted mean difference [AMD], 6.6 [95% CI, −9.5 to 22.7], Urinary Distress Inventory scores of −75.8 and −80.3, respectively; AMD, 4.5 [95% CI, −10.3 to 19.3], and Colorectal-Anal Distress Inventory scores of −41.7 and −44.5, respectively; AMD, 2.8 [95% CI, −16.1 to 21.7].

The authors suggest that their findings illustrate that these surgical procedures do not work as well in the long term as surgeons once thought. However, because patient quality of life was still high, the procedures still remain options for patients. Pelvic surgeons should extend their postoperative care for these patients and should approach prolapse treatment as something to monitor long term.

ACOG Committee Opinion focuses on postpartum care

The American College of Obstetricians and Gynecologists (ACOG) has released a revised Committee Opinion to emphasize the idea of the “fourth trimester” in an attempt to reduce maternal morbidity and mortality numbers. Committee Opinion #736, “Optimizing Postpartum Care” will be published in the May issue of Obstetrics and Gynecology.

ACOG had previously recommended a comprehensive postpartum appointment be scheduled within the first 6 weeks after birth. The revised Committee Opinion now suggests that all women meet with an ob/gyn or other obstetric care provider within the first 3 weeks postpartum and that postpartum care now be considered a long-term and ongoing process.  

The initial assessment should be followed with ongoing care as needed and should conclude with a comprehensive postpartum visit no later than 12 weeks after birth. The last visit should be focused on the mother and should assess her mood and emotional well-being, infant care and feeding, sleep and fatigue, sexuality, contraception and birth spacing, physical recovery from birth, chronic disease management, and health maintenance.

Beyond the immediate care provided to new mothers and infants, there is also the hope that approaching postpartum care as a long-term practice will help reduce health disparities among populations with limited access to resources. According to ACOG, currently as many as 40% of women who give birth do not attend a postpartum visit. ACOG also recommends that obstetricians begin counseling patients about postpartum care during pregnancy. These prenatal discussions should go over the mother’s reproductive life plans and her desire for and the timing of any future pregnancies.

Does age at menopause affect cognitive ability?

A study published in Neurology suggests that entering menopause later in life may be associated with a small boost in memory performance years later. The authors believe the results show that lifelong hormonal processes, rather than just short-term fluctuations during menopause, may be associated with cognitive ability.

The study involved a sample of 1,315 women from the Medical Research Council National Survey of Health and Development in Great Britain. The women involved in the survey have been followed since birth in March 1946.  The women’s verbal memory and processing speed was assessed four times between ages 43 and 69 – at ages 43, 53, 60-64 and 69 years. The researchers used a 15-item word learning test which was repeated 3 times and involved having participants recall as many words as they could; a perfect score was 45. Two sets of word lists were alternated to minimize practice effects. In addition, processing speed was assessed using a visual search task that gave participants 1 minute to cross out as quickly and accurately as possible the letters P and W randomly embedded in a grid of other letters; a perfect score was 600.

Menstrual irregularity and cessation were self-reported and validated against hospital records. Information regarding any operation to remove the uterus or ovaries as well as monthly hormone replacement therapy (HRT) use was also obtained. The researchers calculated months since birth until periods ceased naturally, or because of bilateral oophorectomy (with or without hysterectomy), or because of hysterectomy with or without unilateral oophorectomy. Women whose periods stopped for other reasons, such as chemotherapy, were excluded from the study (n=37). Women who started HRT before menopause and had not ceased HRT for at least a year from the main analysis were also excluded since it was not possible to assign a date of menopause (n=122). The researchers also controlled for childhood cognitive ability, education, body size, smoking history, and occupational class.

In the memory test, the participants recalled an average of 25.8 words at age 43. By age 69, the average number of words dropped to 23.3 words. Among the 846 women who experienced menopause naturally, the women who had later menopause had higher verbal memory scores and remembered 0.17 additional words per year. After adjusting for covariates, the difference was 0.09 additional words per year. Among the 313 women who experienced menopause due to surgery, the association between age and memory scores was no longer present after adjusting for other variables. The researchers found no relationship between the participants’ information processing rate and age at menopause.

Regarding HRT, it was only protective for cognitive processing speed in women who had undergone bilateral oophorectomy.  The HRT results in this study may not be generalizable to women born later than this cohort because they are less likely to use the drugs. Any positive associations between HRT and cognition, they said, also may have been weakened if the hormones were prescribed only to women at high risk of adverse health conditions. However, the outcomes for HRT are consistent with recent trials in younger women and the Women’s Health Initiative Memory Study, which showed an increase in dementia cases in women aged 65 to 79 in the combined and estrogen-only arms of the trial.

The authors said their results indicate that modifiable factors that delay reproductive aging may have small beneficial effects on cognition in later life. Whether the benefit to memory translates into reduced risk of dementia remains to be determined and further studies are needed to fully assess the clinical significance of the associations.