Hypothesis / aims of study
Pelvic organ prolapse (POP) is often thought to predominantly affect postmenopausal women, however its prevalence among younger individuals is increasingly recognised (1). Management in this group poses unique challenges due to multifaceted considerations, including fertility preservation, sexual function, and the maintenance of femininity (2). Despite this, no existing literature exclusively focuses on premenopausal women, offering limited insights into the impact and treatment outcomes of POP in this group.
This study aimed to 1) evaluate the safety and effectiveness of POP procedures in premenopausal women, and 2) compare surgical access and management preferences between premenopausal and postmenopausal cohorts.
Study design, materials and methods
A retrospective cohort study was conducted involving 71 premenopausal and 127 postmenopausal women who underwent POP surgery at a UK tertiary care centre between September 2015 and March 2024. Ethical registration was for service evaluation. All patients provided informed consent.
Data collected included demographics, reproductive history, conservative management uptake, surgery type, complications, anatomical and patient-reported outcomes (PROs). POP was assessed using the Pelvic Organ Prolapse Quantification System (POP-Q), with pre- vs. post-operative changes calculated. Subjective outcomes were evaluated via the Patient Global Impression of Improvement (PGI-I) and changes in the International Consultation on Incontinence Questionnaire – Vaginal Symptoms (ICIQ-VS). Statistical significance was assessed using the Wilcoxon signed-rank test for pre- vs. post-operative changes, and the Mann-Whitney U test and Chi-Squared test for inter-cohort comparisons of continuous and categorical variables, respectively.
Results
The median age was 40 (IQR: 36 – 43.5) years in the premenopausal group and 76 (IQR: 71 – 79) years in the postmenopausal group (p < 0.0001). Parity, POP-Q stage distribution, and BMI were comparable (p < 0.05).
In the premenopausal cohort, 84.5% had completed families, and 57.75% used contraception, predominantly hormonal methods. Surgical interventions included uterus-sparing procedures (57.75%), such as sacrocolpohysteropexy (11.27%), anterior pelvic floor repairs (14.08%), and posterior pelvic floor repairs with or without perineorrhaphy and sacrospinous fixation (29.58%), while vaginal hysterectomy was performed in 40.85%. Subjective improvement was reported by 63% as per PGI-I. Significant improvements were noted in ICIQ vaginal symptoms (median reduction: 25; p < 0.00001), sexual symptoms (median reduction: 17; p = 0.00096), and quality of life domains (median reduction: 6; p < 0.00001). POP-Q scores improved significantly in all compartments (p < 0.005). Complication rates were low, with 1.41% readmission for perineal wound dehiscence and no reoperations. Early recurrence, within the 3-6 months, was observed in 4.11% of cases.
Pelvic floor therapy participation was similar between groups (42.52% vs. 42.25%, p > 0.05), but pessary use was significantly lower in premenopausal women (50.7% vs 77.95%, p = 0.0002). Of note, uterus-preserving surgery was more common in postmenopausal women (77.17% vs 57.75%, p = 0.01). Surgical wait times were prolonged in both groups: median 266 days (premenopausal) vs 282 days (postmenopausal) (p = 0.79). No significant differences were noted in wait times across POP stages 2–4 (p > 0.05).
Sample size achieved >80% power to detect clinically meaningful differences in symptom scores and management trends.
Interpretation of results
POP surgery in premenopausal women demonstrates strong safety and efficacy, with significant anatomical and PRO improvements, across POP-Q, vaginal symptoms, sexual health concerns, and overall quality of life. Uterus-sparing procedures were favoured in both premenopausal and postmenopausal groups. Despite this, there are significant delays in access to surgery and lower uptake of conservative treatments in premenopausal women, highlighting unmet needs in care pathways.