Can you use vaginal estrogen with a pessary or prolapse?
Yes. Vaginal estrogen is commonly used alongside a pessary to keep the vaginal tissue healthy, and it may help some women stay on their pessary longer. The evidence supporting it has real limits, though, and it helps to understand what vaginal estrogen can and cannot do here.
Why it is used with a pessary
A pessary is a removable device that sits in the vagina and presses against the vaginal wall to support prolapsed tissue. That steady pressure is what makes the device work, but it also means the condition of the vaginal lining matters. Thinner, less estrogenized tissue, common after menopause, tolerates the constant contact less well. Healthier, better-estrogenized tissue is more resilient.
This is the rationale for pairing the two. In the AUGS-SUNA pessary consensus, vaginal estrogen may be considered for women who want to optimize long-term pessary use. One study found that women using vaginal estrogen were less likely to discontinue their pessary. Pessary users have also been reported to have lower discontinuation rates and less bothersome vaginal discharge when they use vaginal estrogen at the same time.
The limit worth knowing
Interestingly, vaginal estrogen has not been shown to prevent the skin abrasions a pessary can cause. Several well-designed studies found no difference in abrasion rates between women who used vaginal estrogen and women who did not. So estrogen may support the tissue and may help you keep the pessary, but it is not a guaranteed shield against the small skin injuries that pessaries sometimes produce. Regular follow-up examinations remain the way those injuries are found early and addressed. A first check within about four weeks of the fitting, then maintenance visits after that, is the standard rhythm, and it does not change just because you are also using estrogen.
When a pessary causes an erosion
If a pessary causes an erosion, a deeper break in the vaginal lining, and you are not already using vaginal estrogen, a trial of vaginal estrogen while continuing the pessary is a reasonable step. If instead the erosion is enlarging or getting deeper, the approach changes. The pessary is removed for about four weeks and vaginal estrogen is used while the tissue heals, after which the pessary can often be refitted, sometimes in a different size or type.
What is not settled
The best frequency, duration, and formulation of vaginal estrogen for pessary care have not been established. Practice varies, and cost and personal preference reasonably factor into the decision. This is the same low-dose local therapy used for genitourinary syndrome of menopause (GSM), sometimes still called vaginal atrophy.
Does it treat the prolapse?
No. Vaginal estrogen improves the condition of the vaginal tissue. It does not lift or correct the prolapse itself. The pessary provides the physical support, and the estrogen simply helps the surrounding tissue tolerate the device and stay healthy. Vaginal estrogen can also be used before a fitting when significant tissue thinning makes the exam uncomfortable, giving the lining a couple of months to improve first.
How I approach it
When I fit a pessary in a postmenopausal woman, I usually talk through vaginal estrogen as a way to help the tissue tolerate the device over the long run. If an erosion shows up, estrogen is one of the tools I reach for, matched to how the tissue looks rather than used on autopilot.
References
- Hooper GL, Moynihan L, Leegant A, et al. Vaginal Pessary Use and Management for Pelvic Organ Prolapse. Urogynecology. 2023. doi:10.1097/SPV.0000000000001293
- Faubion SS, Kingsberg SA, Clark AL, et al. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020. doi:10.1097/GME.0000000000001609
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