Abstract
In the last of these commentaries, I discussed the case of a younger women affected by menopause. Dorothy is now 95 and at quite the other end of the spectrum. We used to talk about spending half of adult life after the cessation of bleeding. Increasing it is becoming half of total life. The loss of estrogen can have very long-term ramifications.
Dorothy first came to see me over three years ago at the suggestion of a friend. Four or five years before that she had had a vaginal prolapse diagnosed and a 71-mm PVC ring pessary fitted in gynaecology outpatients. This initially controlled the prolapse but a significant erosion had been noted when the ring had been changed about six months earlier. On that occasion, about an hour after refitting, the prolapse had seemed to come down further than it had done previously, despite the ring remaining in place. This was associated with a dragging pelvic discomfort.
Dorothy had been referred to gynaecology outpatients. A variety of alternative pessaries had been tried including gelhorn and silicone diaphragm pessaries. She remained uncomfortable and on one occasion been admitted to hospital for packing when there had been an episode of fresh bleeding. On the assumption that the erosion was the problem, a smaller pessary had been tried but this had failed to control the prolapse. A bulge had been protruding and rubbing on underwear. It made sitting uncomfortable. At times, Dorothy had to lie down to reduce its size in order to be able to pass urine. Incontinence, however, was more usual. Bowel function was impaired and she could only pass small amounts of stool with discomfort. She was at the end of her tether.
At the last outpatient appointment, surgery had been offered as the only remaining option. She was put on a waiting list and had been advised to apply 0.01% estriol cream weekly in the interim. She had done so for six weeks but was unhappy about going ahead.
Dorothy came to see me to discuss her options. Was there anything else she could try? Although of sound mind she had atrial fibrillation and angina and felt – probably correctly – that surgery would kill her. She was also anti-coagulated with warfarin and wanted to continue with this.
Having established the evolution of the problem, I ran through my usual questions: despite her age. I needed to understand the background. I established that menopause had occurred in the early 50 s; no hormone replacement therapy had been offered. I asked about flushes, sleep disturbance, mood, memory and joint pain to exclude any significant residual systemic estrogen deficiency component. I asked about vaginal dryness and sex (yes, even when over 90 but very sensitively) and established that there was significant incontinence as well as discomfort associated with the prolapse. It was causing enough disruption to life to demand intervention.
Examination revealed a frankly atrophic anterior vaginal wall prolapsing in front of an inadequate 68 mm silicone ring pessary with diaphragm. It was hardly surprising that she was incontinent and uncomfortable. On removal, there was an erosion of the posterior vaginal wall that oozed briskly.
The next step was to explain to her the problem and make sure that she thoroughly understood. We discussed and agreed a plan to try to manage this conservatively.
This would entail enough topical estrogen to reverse atrophy and return some lubrication, elasticity and resilience to the vaginal wall. This with time should facilitate the placement of adequate mechanical support. The strategy was to develop sufficient stretch in the vaginal wall to place a large enough pessary to support the prolapse and limit erosion from friction.
I fitted an 80-mm PVC pessary and then replaced the silicone pessary within it to support the anterior wall. This was intended as a short-term measure. I ensured that Dorothy was comfortable and could pass urine (i.e. there was no obstruction to the bladder outflow). I asked her to increase to the more concentrated 0.1% estriol cream and to use this daily – placed as high as she was able within the vagina.
Dorothy remained comfortable for two weeks but returned when discomfort and a bulge returned. Again the anterior wall was prolapsing, as the ring had slipped off the pubic shelf. Already the vagina was looking different. There was no erosion. I replaced the two pessaries with a single 83 mm silicone folding pessary with support.
A month later, Dorothy had formally cancelled her surgery. She was more comfortable though felt that the second two weeks of the month had not been as good as the first. The pessary had again slipped off the pubic shelf but there was no vaginal wall prolapse anterior to it. The atrophy was clearly being reversed with the vaginal wall becoming paler, more elastic and lubricated. There was no erosion.
On this occasion, the vagina accommodated an 89-mm silicone ring pessary with support. Above it, I placed an estradiol releasing vaginal ring that would last 12 weeks. Dorothy was asked to apply the estriol cream every other day to the lower vagina and introitus.
Since then, once every three months, I remove both rings, inspect the vagina, fit a replacement estradiol releasing ring but wash and replace the silicone pessary. Three years on it looks as good as new. Dorothy is still using estriol cream but has gone down to the 0.01% product on alternate days as she finds this easier to use.
This is undoubtedly a success for patience as well as estrogen. It is vital that patients can understand, agree to and comply with what they are asked to do. If capacity is present age does not contraindicate. This tale has shown that it is possible to reverse vaginal atrophy even into the 90 s and to do so sufficiently that comfort and dignity can be preserved. Where there is published evidence it confirms the experience that supportive pessaries can help women with prolapse but will work much, much better if the vagina is estrogenised. Do not deny older women this option.
What might be the risk? We have discussed and accept that Dorothy has established coronary heart disease; however, the systemic effect of vaginal estrogen is minimal. The warfarin will counter any remote thrombotic influence. At the doses used, promotion of breast cancer will be insignificant. There is a very tiny possibility that using estriol cream as well as the ring might, just might, cause endometrial stimulation but have taken a considered decision together that this risk at 95 is not going to be significant. These minimal risks are less than that of doing nothing and much less than that of surgery. They have been openly discussed and an informed decision made.
On one occasion, there was a brisk and heavy bleed but it was associated with massive constipation causing friction of the posterior wall. Great effort has since been made to avoid this recurring. We have even discussed stopping the warfarin to limit such bleeding but Dorothy – who is quite able to evaluate and balance risk would prefer to continue.
We have thus agreed an honourable compromise – no surgery, comfort, reasonable continence and quality of life. It would not have been possible without the vaginal estrogen and it is never too late to consider this option.