Pelvic organ prolapse (POP) is a common disorder, where 38–50% of postmenopausal women are affected with Stage II prolapse or more [
1‐
4]. Women with POP can experience a sensation of heaviness or bulging in the vagina, and can have problems with voiding, defecation and sexual functioning. These POP-related symptoms adversely affect women’s quality of life, body image as well as their productivity [
5‐
7].
Surgery is often indicated to relieve symptoms, and women have a 11–19% lifetime risk of undergoing surgery for POP [
8‐
10]. However, surgery for POP is associated with high recurrence rates around 30% [
9,
11‐
14], which necessitates additional research to improve surgical outcome for POP.
It is hypothesized that vaginal estrogen therapy might improve surgical outcome for POP and subsequent POP-related symptoms. Yet estrogen therapy has shown to be beneficial for women with divers pelvic floor pathology. Vaginal atrophy can be solved by the use of vaginal estrogen therapy, effectively treating bothersome symptoms like vaginal dryness, and itching of the vulva [
15]. In addition, a reduction of symptoms has also been described in women with prolapse symptoms, stress urinary incontinence, overactive bladder symptoms and recurrent cystitis, after using vaginal estrogen [
16‐
18]. The hypothesis is that estrogen results in a thickening of the vaginal wall and urothelium, and improves vascularization of the pelvic floor [
18]. Multiple in-depth studies have been performed to investigate the potential beneficial effects of vaginal estrogen therapy [
19‐
21]. A randomized trial showed that the use of vaginal estrogen prior to prolapse surgery increased the production of collagen and reduced degradative enzyme activity [
22]. Moreover, estrogens act on the cutaneous wound healing response by modulating the inflammatory response, cytokine expression and matrix deposition [
18]. In addition, estrogens accelerate re-epithelialization, stimulating angiogenesis and wound contraction, and regulate proteolysis [
18,
23]. Consequently, it is thought that women with low estrogen levels who undergo surgery for POP might have a higher risk of recurrence of their POP—and subsequent symptoms—due to poor vascularization and a thin vaginal wall, compromising their healing capacity. Vaginal estrogen administration is expected to improve healing and long-term maintenance of connective tissue integrity of the pelvic floor [
23,
24] and therefore reduce risk of recurrence. Nevertheless, limited supportive data can be found regarding the use of perioperative estrogen to improve clinical outcomes following surgical intervention for prolapse. This was confirmed in a Cochrane review which concluded that a randomized controlled trial is needed to assess perioperative estrogen therapy as adjunctive treatment for women undergoing prolapse surgery [
25,
26]. Hence, this study is conducted and aims to evaluate the cost-effectiveness of perioperative vaginal estrogen therapy in postmenopausal women undergoing POP surgery. The results of this study will provide evidence whether the use of estrogen is effective in reducing recurrent POP symptoms, reoperations for POP and hence its cost-effectiveness.