From tissue to outcome - how perioperative vaginal estrogen transforms prolapse surgery results: a systematic review and meta-analysis of clinical evidence and outcomes.

Pelvic organ prolapse affects millions of postmenopausal women worldwide, frequently requiring surgical intervention when conservative treatments fail. This systematic review and meta-analysis evaluated the effectiveness and safety of perioperative vaginal estrogen therapy in postmenopausal women undergoing prolapse surgery. Nine randomized controlled trials including 764 women (383 estrogen, 381 controls) were analyzed through December 2024. Meta-analyses demonstrated significant tissue quality improvement (standardized mean difference 0.73, 95% confidence interval [CI] 0.16-1.30, p = 0.012) with substantial heterogeneity (I2 = 86.7%). However, urinary tract infection effects were inconclusive and contradictory (risk ratio [RR] 0.75, 95% CI 0.27-2.04, p = 0.570, I2 = 67.2%), with one study showing harm and two studies showing benefit. Composite surgical success showed no difference (RR 0.94, 95% CI 0.83-1.06, p = 0.297), with trends toward lower success in estrogen groups. Patient satisfaction was universally high (>95%) regardless of treatment. Vaginal atrophy symptoms improved significantly with estrogen. Safety profiles were excellent. Current evidence supports perioperative vaginal estrogen for tissue quality optimization and atrophy symptom management, but not for preventing complications or enhancing surgical success.