Deborah Howell (Host): A majority of women with pelvic organ prolapse are asymptomatic, and you may be able to relieve some symptoms without surgery. Today, we'll learn more about non-surgical treatment for pelvic organ prolapse, or POP, so you can be more informed about your available treatment options. I'm Deborah Howell, and my guest today is Dr. Allen Mehr, a Board Certified Urogynecologist and Reconstructive Pelvic Surgeon at the Pelvic Health and Wellness Center. Welcome, Dr. Mehr.

Allen Mehr, DO, FACOG: Hi Deborah, thanks for having me.

Host: I'm excited about this one. Can we dive right in?

Allen Mehr, DO, FACOG: Absolutely.

Host: All right. What is pelvic organ prolapse?

Allen Mehr, DO, FACOG: Pelvic organ prolapse is essentially a hernia. That's kind of what I think of and it's quite common and it's also been described as kind of a descent of any of the pelvic organs. So the bladder, the uterus, or the back of the vaginal wall.

Host: Okay. Is this common?

Allen Mehr, DO, FACOG: It is really common, actually. I would say maybe about a third of moms who've had babies have some pelvic or loss of pelvic organ support or prolapse. But it's not always symptomatic.

Host: Is pelvic organ prolapse dangerous?

Allen Mehr, DO, FACOG: It is not dangerous. No, like I said, I would think of it as kind of like a hernia. Some women have symptoms. Other women may not have symptoms, but we've all heard of things like belly button hernias or inguinal hernias or a little bit of weakening of that connective tissue, and it doesn't really, necessarily pose any kind of threat or danger.

Host: Great. That's good to hear. Now, when does POP become a problem?

Allen Mehr, DO, FACOG: Well, I would say pelvic organ prolapse becomes a problem when it impacts quality of life for women. So, if someone feels like they can't do their day to day activities or it's impacting their ability to really enjoy their social life or exercise, or it impacts their sexual health. I would say those are all reasons to kind of seek treatment.

Host: Fair enough. So how do I know if I have prolapse?

Allen Mehr, DO, FACOG: Well, a majority of women, I would say about one in three moms that have had babies have prolapse and most of the time it's asymptomatic and nothing needs to be done about it. But if there are symptoms like a vaginal bulge or pressure, I think it's really important to see your primary care doctor, or your OBGYN, and just kind of start that conversation and see is there potentially something going on where they need to refer you to see me.

Host: Right, and when you're with your physician, that is the time to ask, will this get worse?

Allen Mehr, DO, FACOG: That's a really good question. We've looked at some studies a couple years out and a majority of the time, I would say 80 percent of the time, it doesn't necessarily get worse. For some women, prolapse actually gets better. About 10 percent of women actually have improvement of their prolapse and their symptoms.

And only about 10 percent of women get worse. So I would say, 90 percent of the time, if someone has a particular stage of prolapse, it tends to stay the same or slightly improve.

Host: That's excellent news. What are some risk factors for pelvic organ prolapse?

Allen Mehr, DO, FACOG: I would say the most common risk factor is pregnancy. Now it's not necessarily vaginal delivery, we think that it's pregnancy in and of itself and that pregnancy can kind of cause some stretching of the connective tissues and loss of support. There are other risk factors like chronic coughing or really anything where that would increase the pressure in the abdomen, like untreated constipation, overweight or obesity may also play a role.

And there are also, some genetic risk factors in patients that potentially have weakened connective tissues or connective tissue problems.

Host: So what should I do if I have symptoms of prolapse?

Allen Mehr, DO, FACOG: I think the most important step is to seek out your primary care doctor or your OBGYN and really just to start that conversation. A lot of women, unfortunately, are embarrassed to talk about these things, but I think the most important thing would be to kind of normalize discussion, and just understand that this is a common problem; and if it's bothering you, that there are really good treatment options available.

Host: Can this happen after a hysterectomy as well?

Allen Mehr, DO, FACOG: Hysterectomy is actually a risk factor for prolapse, prolapse progression as well. There are some connective tissues and ligaments that help hold up the top of the vagina. And these are typically cut during a hysterectomy. So I think it's really important that women know that if they're having a hysterectomy, that can predispose them to developing prolapse, or if they already have some mild degree of loss of support, that it could kind of make those symptoms a little bit worse.

Host: Okay, thanks for clarifying that. So when do I need to treat prolapse?

Allen Mehr, DO, FACOG: I think it kind of goes back to when to kind of seek treatment. If you notice that this is really bothering you and impacting your ability to stay active and play sports, go hiking, engage in social activities, or you know, it's uncomfortable or it's rubbing on your underwear and you just don't feel like yourself and you feel like this is really impacting your quality of life; that's the time to seek care.

Host: So is additional testing beyond a history and physical examination needed to evaluate women with prolapse?

Allen Mehr, DO, FACOG: Sometimes. When we discuss other symptoms, such as urinary symptoms, if someone reports things like stress incontinence, which is leaking with coughing, laughing, sneezing, or overactive bladder symptoms, like urinary urgency or frequency, we may do additional what we call bladder function testing to see if there are other urinary symptoms that may go hand in hand with the prolapse.

But for the most part, I think a careful history and physical exam is what's needed to kind of diagnose, evaluate, and provide treatment options for prolapse.

Host: Alright, speaking of treatment options, what are pessaries?

Allen Mehr, DO, FACOG: Ah, yes. So pesseries would kind of fall into, I would say, the two really big branches of treatment are non-surgical and surgical options for prolapse. And pessary would be kind of a mainstay and I think every woman should be offered a pessary for treatment of prolapse.

Host: Okay, how long have pessaries been around?

Allen Mehr, DO, FACOG: Well, pessaries are support devices that I think in their modern form now, we make out of silicone, but they've actually been around for thousands of years, believe it or not, going back to Hippocrates and even in the Egyptian papyruses, there's been records of pessaries used at the time.

Now, although the materials have kind of changed over time, they've all kind of served the same function, whether they were brass or if they were wool and wax or even fruit that have really been designed to kind of help women over thousands of years to manage their prolapse.

Host: And who should consider a pessary?

Allen Mehr, DO, FACOG: I think every woman should consider a pessary. Surgical treatment options, while they're good, they have significant risks. So I think it's like any assistive device, really. It's like having glasses or contact lenses, you know. You don't necessarily need to have surgery. And some women don't want the downtime or the risks associated with surgery.

So I think everybody should certainly consider it. We're able to actually fit a majority of women for pessaries and a significant number of women also continue them because they just work.

Host: Are there any contraindications to pessary use?

Allen Mehr, DO, FACOG: Well, I would say if there's something going on, like an active infection in the vagina, or if there's an untreated or undiagnosed lesion or ulcer, I would say those are kind of big contraindications. The other really important thing is it's important to have a patient that has really good follow up and is willing to kind of manage and care for the pessary. You don't want to utilize a pessary in someone who may have altered mental status or dementia where they potentially could forget that the pessary is there and then months later or a year later have a complication associated with the pessary.

Host: I just have a couple more questions for you. This is really, really interesting. Are there any lifestyle modifications that can help with prolapse?

Allen Mehr, DO, FACOG: Some of the risk factors like smoking, if someone develops a chronic cough, or you know, poorly treated asthma, those kinds of conditions would put a lot of pressure down into the pelvis and that kind of repeated straining can essentially make a hernia worse.

So I think that anytime there's a cough or a chronic cough, I think it's important to seek care and get that treated and optimized. And being overweight or obesity, that can also put more pressure into the pelvis. And lastly, I would say if there are things like really heavy weight lifting, or if somebody's constipated and they're straining a lot to have bowel movements, all those things can kind of make prolapse worse. So I would say those are some things that we can certainly help in terms of modifying.

Host: Okay, and my last question to you is, does vaginal estrogen have a role in treatment of prolapse symptoms?

Allen Mehr, DO, FACOG: Yeah, so vaginal estrogen has been around for quite some time and it is very, very safe .After menopause, the average age of menopause being age 51; the vaginal tissues tend to become a little;bit more thin due to the loss of estrogen. And if someone is utilizing something like a pessary, which is a foreign body, it can kind of irritate the tissues in the vagina. So a lot of times if we're utilizing a pessary or someone has prolapse symptoms, estrogen has a really important role in that it helps make the vaginal tissues healthier, a little bit more robust, and can also help with a myriad of other symptoms like overactive bladder and dyspareunia or what we call pain with intercourse.

Host: I have to say, you're such a calming presence that even when you hear the word dyspareunia, from you, it doesn't feel like anything we can't handle together. Thank you so much for all you bring to the table, Dr. Mehr, and how much you help our patients. Thanks for being with us today.

Allen Mehr, DO, FACOG: Thanks for having me today, Deborah.

Host: And that wraps up this episode of the podcast series from Deaconess the Women's Hospital, a place for all your life. For more information, please visit deaconess.com/pelvichealth. Please remember to subscribe, rate, and review this podcast and all the other Deaconess Women's Hospital podcasts. For more health tips and updates, follow us on your social channels. I'm Deborah Howell. Thanks for listening and have yourself a great day.