Salpingo-oophorectomy at the Time of Benign Hysterectomy: A Systematic Review.

OBJECTIVE: To compare the long-term risks associated with salpingo-oophorectomy with ovarian conservation at the time of benign hysterectomy. DATA SOURCES: MEDLINE, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials were searched from inception to January 30, 2015. We included prospective and retrospective comparative studies of women with benign hysterectomy who had either bilateral salpingo-oophorectomy (BSO) or conservation of one or both ovaries. METHODS OF STUDY SELECTION: Reviewers double-screened 5,568 citations and extracted eligible studies into customized forms. Twenty-six comparative studies met inclusion criteria. Studies were assessed for results, quality, and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant, intervention, comparator, and outcomes data. When compared with hysterectomy with BSO, prevalence of reoperation and ovarian cancer was higher in women with ovarian conservation (ovarian cancer risk of 0.14-0.7% compared with 0.02-0.04% among those with BSO). Hysterectomy with BSO was associated with a lower incidence of breast and total cancer, but no difference in the incidence of cancer mortality was found when compared with ovarian conservation. All-cause mortality was higher in women younger than age 45 years at the time of BSO who were not treated with estrogen replacement therapy (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.04-1.92). Coronary heart disease (HR 1.26, 95% CI 1.04-1.54) and cardiovascular death were higher among women with BSO (HR 1.84, 95% CI 1.27-2.68), especially women younger than 45 years who were not treated with estrogen. Finally, there was an increase in the prevalence of dementia and Parkinson disease among women with BSO compared with conservation, especially in women younger than age 50 years. Clinical practice guidelines were devised based on these results. CONCLUSION: Bilateral salpingo-oophorectomy offers the advantage of effectively eliminating the risk of ovarian cancer and reoperation but can be detrimental to other aspects of health, especially among women younger than age 45 years.

Pain Scores and Exposure Rates after Polypropylene Mesh for Pelvic Organ Prolapse.

OBJECTIVES: To characterize pain and exposure after Prolift placement and identify risk factors. METHODS: A case series of women who underwent Prolift vaginal mesh were surveyed. Pain was assessed using a visual analog scale. Exposure was evaluated clinically. RESULTS: Of 183 eligible patients, 160 completed the survey, and 45 returned for examination. Mean preoperative pain score was 0.97 and postoperative was 1.35 (P = 0.12). Pre- and postoperative pain scores by compartment were: anterior (1.34 vs 1.25, mean change -0.09, P = 0.84), posterior (1.30 vs 1.56, mean change 0.26, P = 0.72), and total (0.63 vs 1.34, mean change 0.71, P = 0.05). Graft exposure was confirmed in 23 of 183 patients (12.6%); however, because asymptomatic patients were not examined, the true exposure rate may be underestimated. Hematoma formation is independently associated with mesh exposure, adjusted odds ratio 18.4 (95% confidence interval 3.4-147.4, P = 0.01). CONCLUSIONS: Although pain scores did not increase overall, there was a trend toward increased pain score in the patients with total (anterior and posterior) Prolift. Hematoma formation was significantly associated with mesh exposure.

Low-dose 17-ß-estradiol cream for vaginal atrophy in a cohort without prolapse: Serum levels and vaginal response including tissue biomarkers associated with tissue remodeling.

OBJECTIVES: Describe the effect of 50 mcg vaginal 17-ß-estradiol (E2) cream on vaginal maturation, serum estrogen levels, atrophic symptoms, and biomarkers of oxidative stress and tissue remodeling in postmenopausal women without prolapse. METHODS: Seventeen women, 65 years or older, applied intravaginal E2 cream nightly for eight weeks, then twice weekly for eight weeks. Vaginal biopsies, serial blood draws, and atrophic symptoms were obtained at baseline, eight, and sixteen weeks. Changes in atrophic symptoms, vaginal maturation indices (VMI), and serum E2 were measured. Immunohistochemical staining characterized levels of transforming growth factor-beta (TGF-ß), nuclear factor kappa B (NFKB), inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS), and thrombospondin (TSP). RESULTS: Serum E2 levels (pg/ml) were unchanged from baseline (mean (SD)) 7.7 (3.3) to eight 9.7 (5.7) and sixteen 8.7 (5.8) (p=0.24) weeks. VMI (mean (SD)) improved from baseline 34.2 (18.3) to eight 56.7 (13.1) and sixteen 54.5 (11.3) (p<0.001) weeks with no difference between eight and sixteen weeks. Vaginal dryness (p=0.03) and itching (p=0.02) improved. Tissue biomarker levels did not change (TGF-ß p=0.35, NFKB p=0.74, eNOS p=0.80, iNOS p=0.24, TSP p=0.80). DISCUSSION: Vaginal E2 improved atrophic symptoms and VMI without elevating serum E2. Tissue remodeling biomarkers did not change.

Life Space Assessment in Older Women Undergoing Non-Surgical Treatment for Urinary Incontinence.

OBJECTIVES: Urinary incontinence (UI) impacts all aspects of life activities. This study aims to characterize change in mobility within the community utilizing the Life Space Assessment (LSA) questionnaire in women undergoing non-surgical UI treatment. DESIGN: Prospective cohort study, performed from July 2007 to March 2009, which followed women seeking non-surgical UI treatment and assessed their mobility and symptoms using LSA, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) at baseline and 2, 6, and 12 months post-treatment. Estimated Percent Improvement (EPI) and Patient Satisfaction Question (PSQ) were obtained post-treatment. SETTING: Outpatient tertiary-care clinic. PARTICIPANTS: 70 ambulatory, community-dwelling women, aged 65 years or older, seeking non-surgical care for UI. INTERVENTION: Multi-component behavioral and/or pharmacologic therapies. MEASUREMENTS: We hypothesized LSA would improve with treatment. Repeated measures analysis with Tukey's HSD and backwards selection linear regression model were performed. RESULTS: LSA score decreased from baseline to 2 months (mean±SD; 63±29 to 56±28, p<0.001) and was sustained at 6 and 12 months (54±28, 54±28). UDI scores improved from 36±23 to 25±24, p<0.001, at 2 months, and improvement persisted at 6 and 12 months (22±22, 21±24). Improvements in UDI and patient perceived improvement in UI were not associated with LSA change. Age, race, and depression impacted LSA, which decreased 1-point for each additional year of age (p=0.004), 6-points for each point higher on the Geriatric Depression Scale (GDS) (p=0.002), and 6-points for African American race (p=0.048). CONCLUSION: Decreased mobility represented by LSA was related to age, depression, and race, but not UI symptom improvement.

Sling surgery for stress urinary incontinence in women: a systematic review and metaanalysis.

OBJECTIVE: Understanding the long-term comparative effectiveness of competing surgical repairs is essential as failures after primary interventions for stress urinary incontinence (SUI) may result in a third of women requiring repeat surgery. STUDY DESIGN: We conducted a systematic review including English-language randomized controlled trials from 1990 through April 2013 with a minimum 12 months of follow-up comparing a sling procedure for SUI to another sling or Burch urethropexy. When at least 3 randomized controlled trials compared the same surgeries for the same outcome, we performed random effects model metaanalyses to estimate pooled odds ratios (ORs). RESULTS: For midurethral slings (MUS) vs Burch, metaanalysis of objective cure showed no significant difference (OR, 1.18; 95% confidence interval [CI], 0.73-1.89). Therefore, we suggest either intervention; the decision should balance potential adverse events (AEs) and concomitant surgeries. For women considering pubovaginal sling vs Burch, the evidence favored slings for both subjective and objective cure. We recommend pubovaginal sling to maximize cure outcomes. For pubovaginal slings vs MUS, metaanalysis of subjective cure favored MUS (OR, 0.40; 95% CI, 0.18-0.85). Therefore, we recommend MUS. For obturator slings vs retropubic MUS, metaanalyses for both objective (OR, 1.16; 95% CI, 0.93-1.45) and subjective cure (OR, 1.17; 95% CI, 0.91-1.51) favored retropubic slings but were not significant. Metaanalysis of satisfaction outcomes favored obturator slings but was not significant (OR, 0.77; 95% CI, 0.52-1.13). AEs were variable between slings; metaanalysis showed overactive bladder symptoms were more common following retropubic slings (OR, 1.413; 95% CI, 1.01-1.98, P = .046). We recommend either retropubic or obturator slings for cure outcomes; the decision should balance AEs. For minislings vs full-length MUS, metaanalyses of objective (OR, 4.16; 95% CI, 2.15-8.05) and subjective (OR, 2.65; 95% CI, 1.36-5.17) cure both significantly favored full-length slings. Therefore, we recommend a full-length MUS. CONCLUSION: Surgical procedures for SUI differ for success rates and complications, and both should be incorporated into surgical decision-making. Low- to high-quality evidence permitted mostly level-1 recommendations when guidelines were possible.

Nonsurgical management of heavy menstrual bleeding: a systematic review.

OBJECTIVE: To compare the effectiveness of nonsurgical abnormal uterine bleeding treatments for bleeding control, quality of life (QOL), pain, sexual health, patient satisfaction, additional treatments needed, and adverse events. DATA SOURCES: MEDLINE, Cochrane databases, and Clinicaltrials.gov were searched from inception to May 2012. We included randomized controlled trials of nonsurgical treatments for abnormal uterine bleeding presumed secondary to endometrial dysfunction and abnormal uterine bleeding presumed secondary to ovulatory dysfunction. Interventions included the levonorgestrel intrauterine system, combined oral contraceptive pills (OCPs), progestins, nonsteroidal anti-inflammatory drugs (NSAIDs), and antifibrinolytics. Gonadotropin-releasing hormone agonists, danazol, and placebo were allowed as comparators. METHODS OF STUDY SELECTION: Two reviewers independently screened 5,848 citations and extracted eligible trials. Studies were assessed for quality and strength of evidence. TABULATION, INTEGRATION, AND RESULTS: Twenty-six articles met inclusion criteria. For reduction of menstrual bleeding in women with abnormal uterine bleeding presumed secondary to endometrial dysfunction, the levonorgestrel intrauterine system (71-95% reduction), combined OCPs (35-69% reduction), extended cycle oral progestins (87% reduction), tranexamic acid (26-54% reduction), and NSAIDs (10-52% reduction) were all effective treatments. The levonorgestrel intrauterine system, combined OCPs, and antifibrinolytics were all superior to luteal-phase progestins (20% increase in bleeding to 67% reduction). The levonorgestrel intrauterine system was superior to combined OCPs and NSAIDs. Antifibrinolytics were superior to NSAIDs for menstrual bleeding reduction. Data were limited on other important outcomes such as QOL for women with abnormal uterine bleeding presumed secondary to endometrial dysfunction and for all outcomes for women with abnormal uterine bleeding presumed secondary to ovulatory dysfunction. CONCLUSION: For the reduction in mean blood loss in women with heavy menstrual bleeding presumed secondary to abnormal uterine bleeding presumed secondary to endometrial dysfunction, we recommend the use of the levonorgestrel intrauterine system over OCPs, luteal-phase progestins, and NSAIDs. For other outcomes (QOL, pain, sexual health, patient satisfaction, additional treatments needed, and adverse events) and for treatment of abnormal uterine bleeding presumed secondary to ovulatory dysfunction, we were unable to make recommendations based on the limited available data.

Endometriosis after laparoscopic supracervical hysterectomy with uterine morcellation: a case control study.

STUDY OBJECTIVE: To compare the incidence of new-onset endometriosis after laparoscopic supracervical hysterectomy (LSH) with uterine morcellation to traditional routes. DESIGN: Single center case-control study (Canadian Task Force classification II-2) of hysterectomies performed from January 2006 through December 2008. PATIENTS: Two hundred seventy-seven laparoscopic supracervical hysterectomies with morcellation (cases) and 187 transvaginal or abdominal hysterectomies without morcellation (controls) were performed from January 2006 through December 2008. INTERVENTIONS: A total of 464 women underwent hysterectomy, 277 cases via laparoscopic supracervical approach (LSH) with morcellation and 187 performed either transvaginally or abdominally without morcellation. Repeat operative procedures were performed for other benign indications on 16 of 464 (3.5%) patients who had undergone prior hysterectomy. MEASUREMENTS AND MAIN RESULTS: One hundred two patients had endometriosis at the time of hysterectomy diagnosed by pathologic evaluation or gross visualization. In those without endometriosis, repeat operative procedures were performed for pain and bleeding in 3.3% (12/362). Sixty percent (3/5) of patients treated with LSH and 28.6% (2/7) of the control group were found to have newly diagnosed endometriosis, conferring a rate of 1.4% (3/217) in the LSH group and 1.4% (2/145) in the control subjects. In patients with endometriosis, repeat operative procedures for pain or bleeding occurred in 2.9% (3/102): 3/60 patients treated with LSH and none in the control group (0/42). Two of these 3 patients undergoing a second surgery had recurrent/continued endometriosis. CONCLUSION: Newly diagnosed endometriosis was noted in 1.4% of patients after hysterectomy, with a similar incidence between the LSH and control groups. Reoperation for those with endometriosis at the time of LSH with morcellation was infrequent, but endometriosis was usually found. Further research is needed to delineate risk factors for development of de novo endometriosis after hysterectomy.

A systematic review comparing hysterectomy with less-invasive treatments for abnormal uterine bleeding.

STUDY OBJECTIVE: To compare hysterectomy with less-invasive alternatives for abnormal uterine bleeding (AUB) in 7 clinically important domains. DESIGN: Systematic review. SETTING: Randomized clinical trials comparing bleeding, quality of life, pain, sexual health, satisfaction, need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options. PATIENTS: Women with AUB, predominantly from ovulatory disorders and endometrial causes. INTERVENTIONS: Systematic review of the literature (from inception to January 2011) comparing hysterectomy with alternatives for AUB treatment. Eligible trials were extracted into standardized forms. Trials were graded with a predefined 3-level rating, and the strengths of evidence for each outcome were evaluated with the Grades for Recommendation, Assessment, Development and Evaluation system. MEASUREMENTS AND MAIN RESULTS: Nine randomized clinical trials (18 articles) were eligible. Endometrial ablation, levonorgestrel intrauterine system, and medications were associated with lower risk of adverse events but higher risk of additional treatments than hysterectomy. Compared to ablation, hysterectomy had superior long-term pain and bleeding control. Compared with the levonorgestrel intrauterine system, hysterectomy had superior control of bleeding. No other differences between treatments were found. CONCLUSION: Less-invasive treatment options for AUB result in improvement in quality of life but carry significant risk of retreatment caused by unsatisfactory results. Although hysterectomy is the most effective treatment for AUB, it carries the highest risk for adverse events.

Clinical practice guideline for abnormal uterine bleeding: hysterectomy versus alternative therapy.

STUDY OBJECTIVE: To develop recommendations in selecting treatments for abnormal uterine bleeding (AUB). DESIGN: Clinical practice guidelines. SETTING: Randomized clinical trials compared bleeding, quality of life, pain, sexual health, satisfaction, the need for subsequent surgery, and adverse events between hysterectomy and less-invasive treatment options. PATIENTS: Women with AUB, predominantly from ovulatory disorders and endometrial causes. INTERVENTIONS: On the basis of findings from a systematic review, clinical practice guidelines were developed. Rating the quality of evidence and the strength of recommendations followed the Grades for Recommendation Assessment, Development, and Evaluation system. MEASUREMENTS AND MAIN RESULTS: This paper identified few high-quality studies that directly compared uterus-preserving treatments (endometrial ablation, levonorgestrel intrauterine system and systemically administered medications) with hysterectomy. The evidence from these randomized clinical trials demonstrated that there are trade-offs between hysterectomy and uterus-preserving treatments in terms of efficacy and adverse events. CONCLUSION: Selecting an appropriate treatment for AUB requires identifying a woman's most burdensome symptoms and incorporating her values and preferences when weighing the relative benefits and harms of hysterectomy versus other treatment options.

Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials.

OBJECTIVES: (1) To systematically collect and organize into clinical categories all outcomes reported in trials for abnormal uterine bleeding (AUB); (2) to rank the importance of outcomes for patient decision making; and (3) to improve future comparisons of effects in trials of AUB interventions. STUDY DESIGN AND SETTING: Systematic review of English-language randomized controlled trials of AUB treatments in MEDLINE from 1950 to June 2008. All outcomes and definitions were extracted and organized into major outcome categories by an expert group. Each outcome was ranked "critically important," "important," or "not important" for informing patients' choices. RESULTS: One hundred thirteen articles from 79 trials met the criteria. One hundred fourteen different outcomes were identified, only 15 (13%) of which were ranked as critically important and 29 (25%) as important. Outcomes were grouped into eight categories: (1) bleeding; (2) quality of life; (3) pain; (4) sexual health; (5) patient satisfaction; (6) bulk-related complaints; (7) need for subsequent surgical treatment; and (8) adverse events. CONCLUSION: To improve the quality, consistency, and utility of future AUB trials, we recommend assessing a limited number of clinical outcomes for bleeding, disease-specific quality of life, pain, sexual health, and bulk-related symptoms both before and after treatment and reporting satisfaction and adverse events. Further development of validated patient-based outcome measures and the standardization of outcome reporting are needed.

Systemic effects of vaginally administered estrogen therapy: a review.

Hormone therapy was considered the standard of care before the publication of the Women's Health Initiative. After the study was published, the use of systemic hormone therapy dramatically decreased resulting in an increased incidence of menopausal symptoms such as hot flashes, vaginal dryness, and dyspareunia experienced by women. Use of vaginal estrogen offers women a unique alternative for relief of these symptoms. This article reviews the systemic effects of vaginally administered estrogen. Effects on serum hormone levels, vasomotor symptoms, lipid profiles, and use in women with breast cancer are reviewed. An accompanying review (J Pelvic Med Surg. 2009;15:105-114.) examines the local effects of vaginally administered estrogen.

Long-Term Outcomes of the Total or Supracervical Hysterectomy (TOSH) Trial.

BACKGROUND: Participants in the multi-center, randomized Total or Supracervical Hysterectomy (TOSH) trial showed within-group improvement in pelvic floor symptoms 2 years post-surgery and no differences between supracervical (SCH) versus total hysterectomy (TAH). This study describes longer term outcomes from the largest recruiting site. STUDY DESIGN: Questionnaires addressing pelvic symptoms, sexual function, and health-related quality of life were administered. Linear models and McNemar's test were utilized. RESULTS: Thirty-seven participants (69%) responded (19 TAH, 18 SCH); mean follow up was 9.1±0.7 years. No between-group differences emerged in urinary incontinence, voiding dysfunction, pelvic prolapse symptoms and overall health related quality of life (HRQOL). Within-group analysis showed significant improvement in the ability to have and enjoy sex (P = 0.002) and in the SF-36 physical component summary score (P = 0.03) among women randomized to TAH. CONCLUSION: 9 years after surgery, TOSH participants continue to experience improvement and show no major between-group differences in lower urinary tract or pelvic floor symptoms conferring no major benefit of SCH over TAH.

Obliterative vaginal surgery for pelvic organ prolapse.

Obliterative vaginal surgery is an appropriate management option for pelvic organ prolapse in women who do not desire future vaginal intercourse. When colpoclesis is not technically feasible, constricting repairs can be performed. Obliterative surgery in older women has the advantages of fewer complications and less surgical time than reconstructive procedures, especially in those with medical comorbidities. Age-related changes in physiology should be kept in mind along with the risk of postoperative delirium. Candidates should be counseled regarding high success and satisfaction rates.

Life-space assessment in urogynecology and gynecological oncology surgery patients: a measure of perioperative mobility and function.

OBJECTIVE: To assess the effect of gynecological surgery on mobility and functional status in women aged 60 and older using Life-Space Assessment (LSA). DESIGN: Observational prospective cohort study. SETTING: Academic outpatient urogynecology and gynecological oncology clinics. PARTICIPANTS: Women presenting for urogynecology (n=51) and gynecological oncology (n=51) surgery. MEASUREMENTS: LSA scores 6 weeks, 6 months, and 1 year after surgery. Information on participant demographics, preoperative diagnoses, surgical approach, and medical comorbidities was collected. Analyses used repeated measures. RESULTS: Mean age was 71 +/- 7. Urogynecology participants started and maintained a higher LSA (P=.03) than oncology participants at all study intervals. Six weeks after surgery, urogynecology and oncology participants' mean decline was 13 points (95% confidence interval (CI)=4-21; P=.004) and 23 points (95% CI=13-33; P<.001), respectively. At 6 months, the urogynecology and oncology participants' scores increased by a mean of 9 points (95% CI=1-17; P=.03) and 13 points (95% CI=5-20; P=.001), respectively. No significant difference was found 1 year from baseline within each group or between groups in LSA scores. Income, depression, body mass index, and having an operative complication predicted a larger decline in life-space over time in both groups. CONCLUSION: Gynecological surgical interventions in older women limit physical and functional ability at 6 weeks after surgery. The urogynecology and gynecological oncology cohorts returned to baseline levels by 6 months, which was sustained to 1 year.

Defining success after surgery for pelvic organ prolapse.

OBJECTIVES: To describe pelvic organ prolapse surgical success rates using a variety of definitions with differing requirements for anatomic, symptomatic, or re-treatment outcomes. METHODS: Eighteen different surgical success definitions were evaluated in participants who underwent abdominal sacrocolpopexy within the Colpopexy and Urinary Reduction Efforts trial. The participants' assessments of overall improvement and rating of treatment success were compared between surgical success and failure for each of the definitions studied. The Wilcoxon rank sum test was used to identify significant differences in outcomes between success and failure. RESULTS: Treatment success varied widely depending on definition used (19.2-97.2%). Approximately 71% of the participants considered their surgery "very successful," and 85.2% considered themselves "much better" than before surgery. Definitions of success requiring all anatomic support to be proximal to the hymen had the lowest treatment success (19.2-57.6%). Approximately 94% achieved surgical success when it was defined as the absence of prolapse beyond the hymen. Subjective cure (absence of bulge symptoms) occurred in 92.1% while absence of re-treatment occurred in 97.2% of participants. Subjective cure was associated with significant improvements in the patient's assessment of both treatment success and overall improvement, more so than any other definition considered (P<.001 and <.001, respectively). Similarly, the greatest difference in symptom burden and health-related quality of life as measured by the Pelvic Organ Prolapse Distress Inventory and Pelvic Organ Prolapse Impact Questionnaire scores between treatment successes and failures was noted when success was defined as subjective cure (P<.001). CONCLUSION: The definition of success substantially affects treatment success rates after pelvic organ prolapse surgery. The absence of vaginal bulge symptoms postoperatively has a significant relationship with a patient's assessment of overall improvement, while anatomic success alone does not. LEVEL OF EVIDENCE: II.

Synthetic graft use in vaginal prolapse surgery: objective and subjective outcomes.

INTRODUCTION AND HYPOTHESIS: This study reports 1-year outcomes in women who underwent transvaginal pelvic organ prolapse (POP) surgery with Prolift transvaginal mesh. METHODS: Pre- and postoperative objective vaginal Pelvic Organ Prolapse Quantification (POP-Q) and subjective symptom and impact assessments (Pelvic Floor Distress Inventory (PFDI)-20 and Pelvic Floor Impact Questionnaire (PFIQ)-7, respectively) were performed. Postoperative vaginal tenderness, stricture, and patient satisfaction were also obtained. Paired t tests were utilized for analysis. RESULTS: Mean age was 61.8 +/- 9.8 years; mean follow-up interval was 425.0 +/- 80.0 days (range, 237-717). POP-Q measurements of Ba, Bp, and C were significantly improved (all p values

One-year outcomes of tension-free vaginal tape (TVT) mid-urethral slings in overweight and obese women.

INTRODUCTION: The purpose of this study was to assess the impact of body mass index (BMI) on tension-free vaginal tape (TVT) success rates, patient satisfaction, and complications 1 year following surgery. METHODS: Baseline and 1-year postsurgery outcomes were abstracted, including Urogenital Distress Inventory (UDI-6) scores, Incontinence Impact Questionnaire (IIQ-7) scores, and patient satisfaction ratings. Multivariable logistic and linear regression analyses were performed to examine relationships between outcomes and BMI. RESULTS: Subjects (N = 195) with a mean age of 59.3 +/- 12.6 were included. There was significant improvement within each group (all p values <0.01) in total UDI-6 and IIQ-7 scores from baseline to 1 year postsurgery; all groups had high patient satisfaction. No differences in improvement or complications rates were observed among the BMI cohorts (all p values >0.05). CONCLUSION: Differential counseling of overweight or obese women regarding outcomes of the TVT procedure is not supported by these results; longer follow-up is warranted.

The minimum important differences for the urinary scales of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire.

OBJECTIVE: We sought to estimate the minimum important difference (MID) for the Urinary Distress Inventory (UDI), UDI-stress subscale of the Pelvic Floor Distress Inventory, and Urinary Impact Questionnaire (UIQ) of the Pelvic Floor Impact Questionnaire. STUDY DESIGN: We calculated MID using anchor- and distribution-based approaches from a randomized trial for nonsurgical stress incontinence treatment. Anchors included a global impression of change, incontinence episodes from a urinary diary, and the Incontinence Severity Index. Effect size and standard error of measurement were the distribution methods used. RESULTS: Anchor-based MIDs ranged from -22.4 to -6.4 points for the UDI, -16.5 to -4.6 points for the UDI-stress, and -17.0 to -6.5 points for the UIQ. These data were supported by 2 distribution-based estimates. CONCLUSION: Reasonable estimates of MID are 11, 8, and 16 points for the UDI, UDI-stress subscale, and UIQ, respectively. Statistically significant improvements that meet these thresholds should be considered clinically important.

Association between urinary incontinence and depressive symptoms in overweight and obese women.

OBJECTIVE: The objective of the study was to determine the association between urinary incontinence (UI) and depressive symptoms. STUDY DESIGN: The study was a cross-sectional study of 338 incontinent and overweight women at baseline in the Program to Reduce Incontinence by Diet and Exercise trial. Depressive symptoms were defined as a Beck Depression Inventory score of 10 or greater. UI frequency was determined by a 7-day voiding diary. Symptom bother and quality of life were determined using the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Multivariable regression was used to estimate the association between UI and depressive symptoms. RESULTS: Women with depressive symptoms (n = 101) reported a higher mean number of UI episodes per week (28 vs 23; P = .005) and higher (worse) mean scores on the UDI (176 vs 162; P = .02) and IIQ (136 vs 97; P < .001) compared with women without depressive symptoms. The risk of having depressive symptoms increased with each 7-episode increase in UI per week (adjusted odds ratio [AOR], 1.10; 95% confidence interval [CI], 1.01-1.21), each 50-point increase in UDI (AOR, 1.27; 95% CI, 1.01-1.60), and each 50-point increase in IIQ (AOR, 1.44; 95% CI, 1.22-1.71). CONCLUSION: Urinary incontinence frequency, symptom bother, and quality of life are independently associated with depressive symptoms in overweight and obese women.

Local Effects of Vaginally Administered Estrogen Therapy: A Review.

The results of the Women's Health Initiative (WHI) led to a distinct decline in the routine use of estrogen as preventive therapy for vasomotor symptoms, osteoporosis, and cardiovascular disease in postmenopausal women. Without estrogen replacement, one third of women experience symptoms of atrophic vaginitis including dryness, irritation, itching and or dyspareunia. Local application of estrogen has been shown to relieve these symptoms and improve quality of life for these women. In addition, local estrogen therapy may have a favorable effect on sexuality, urinary tract infections, vaginal surgery, and incontinence. This review examines the effects of vaginally applied estrogen on the vaginal epithelium, urethra and endometrium. An accompanying review examines the systemic effects of vaginally applied estrogen.