practitioner. The increasing rate of operations for
uterovaginal prolapse (both repair and hysterectomy)
over time is perhaps surprising, since it is generally held
that the incidence of prolapse is decreasing because of
such factors as better general health, shorter labours,
and increasing use of caesarean section'. This finding
may, however, reflect a change in the threshold for
surgery. There was an apparent tendency for smoking at
entry to the study to protect against prolapse. A possible
explanation might be that women who have a degree of
stress incontinence stop smoking in order to reduce the
amount that they cough. This explanation is supported
by the observation that ex-smokers at entry have a 26%
higher risk of prolapse than nonsmokers. Another
explanation might be that a surgeon will be more reluctant
to operate on a smoker. The analysis found a greater
effect of weight alone on risk of prolapse than it did for
the effect of weight adjusted for height (i.e. obesity
index). However, the true impact of weight and obesity
may be different from that observed, since the analysis
only takes account of these measurements at study
entry. It may be that subsequent weight has a greater (or
indeed, smaller) impact on risk. The observation that
women who were using a diaphragm at entry to the
study were at lower risk of developing prolapse probably
simply reflects the unsuitability of this method of
contraception for women who already have a degree of
prolapse.
There is a linear increase in the cumulative risk of
prolapse requiring further surgery following hysterectomy.
Thus, while the annual risk is low (0-36%), the
lifetime risk can be substantial (5% after 15 years). The
risk is significantly higher if the initial hysterectomy
was performed because of uterovaginal prolapse. It
is useful to quantify this risk for women for whom
hysterectomy is being considered.
The principal purpose of the Oxford-FPA study was
to assess the health effects of oral contraception. After
the age of 45, only women who had never used the pill
or had used it for more than eight years were still
followed up. However, this restriction of follow up is
unlikely to have any important effect on the epidemiology
of prolapse reported in this paper, since no association
was observed between duration of use of the oral
contraceptive pill and risk of prolapse. Furthermore, it
was found that restricting the analysis to women
younger than 45 years did not materially affect the
results.
It should be noted that there are a number of differences
between women in this cohort study and women
in the general UK pop~lation'~W. omen at entry to
this study were less likely to have chronic disease,
to smoke heavily, to be grossly overweight, or to be in
lower social classes than would be expected from the
general population. These differences, with the possible
exception of smoking, would tend to suggest that risk of
prolapse may be higher in the general population than
was observed in this study.
The Oxford-FPA study analysis reported here is
restricted to women with prolapse who were admitted
to hospital. Women with prolapse who did not seek
medical advice or who were managed by their general
practitioner or as an outpatient will not have contributed
to the numerator. Therefore, the incidence rates in this
study are likely to be a significant underestimate of the
burden of prolapse in the community as a whole, but an
accurate reflection of the incidence of prolapse that is
associated with hospital admission.
The analysis can look only at possible risk factors
that were measured in the Oxford-FPA study. Aspects of
obstetric care, such as mode of delivery, timing of first
and second stage, the extent of trauma at delivery, and
the extent to which postnatal exercises were carried out
may all contribute to risk of prolapse. The strong association
between parity and risk of prolapse that was
observed in this study suggests that study of such
obstetric factors may provide important clues as to how
obstetric care might reduce the risk of prolapse in later
life. A neurophysiological study, for example, demonstrated
that long active second stages of labour and
heavier babies were associated with greater damage to
the pelvic floqr as evidenced by electromyelogram
(EMG) changes than other factors such as forceps
delivery and perineal tears20. There is a need for
epidemiological studies to complement this neurophysiological
approach to the problem.
practitioner. The increasing rate of operations for
uterovaginal prolapse (both repair and hysterectomy)
over time is perhaps surprising, since it is generally held
that the incidence of prolapse is decreasing because of
such factors as better general health, shorter labours,
and increasing use of caesarean section'. This finding
may, however, reflect a change in the threshold for
surgery. There was an apparent tendency for smoking at
entry to the study to protect against prolapse. A possible
explanation might be that women who have a degree of
stress incontinence stop smoking in order to reduce the
amount that they cough. This explanation is supported
by the observation that ex-smokers at entry have a 26%
higher risk of prolapse than nonsmokers. Another
explanation might be that a surgeon will be more reluctant
to operate on a smoker. The analysis found a greater
effect of weight alone on risk of prolapse than it did for
the effect of weight adjusted for height (i.e. obesity
index). However, the true impact of weight and obesity
may be different from that observed, since the analysis
only takes account of these measurements at study
entry. It may be that subsequent weight has a greater (or
indeed, smaller) impact on risk. The observation that
women who were using a diaphragm at entry to the
study were at lower risk of developing prolapse probably
simply reflects the unsuitability of this method of
contraception for women who already have a degree of
prolapse.
There is a linear increase in the cumulative risk of
prolapse requiring further surgery following hysterectomy.
Thus, while the annual risk is low (0-36%), the
lifetime risk can be substantial (5% after 15 years). The
risk is significantly higher if the initial hysterectomy
was performed because of uterovaginal prolapse. It
is useful to quantify this risk for women for whom
hysterectomy is being considered.
The principal purpose of the Oxford-FPA study was
to assess the health effects of oral contraception. After
the age of 45, only women who had never used the pill
or had used it for more than eight years were still
followed up. However, this restriction of follow up is
unlikely to have any important effect on the epidemiology
of prolapse reported in this paper, since no association
was observed between duration of use of the oral
contraceptive pill and risk of prolapse. Furthermore, it
was found that restricting the analysis to women
younger than 45 years did not materially affect the
results.
It should be noted that there are a number of differences
between women in this cohort study and women
in the general UK pop~lation'~W. omen at entry to
this study were less likely to have chronic disease,
to smoke heavily, to be grossly overweight, or to be in
lower social classes than would be expected from the
general population. These differences, with the possible
exception of smoking, would tend to suggest that risk of
prolapse may be higher in the general population than
was observed in this study.
The Oxford-FPA study analysis reported here is
restricted to women with prolapse who were admitted
to hospital. Women with prolapse who did not seek
medical advice or who were managed by their general
practitioner or as an outpatient will not have contributed
to the numerator. Therefore, the incidence rates in this
study are likely to be a significant underestimate of the
burden of prolapse in the community as a whole, but an
accurate reflection of the incidence of prolapse that is
associated with hospital admission.
The analysis can look only at possible risk factors
that were measured in the Oxford-FPA study. Aspects of
obstetric care, such as mode of delivery, timing of first
and second stage, the extent of trauma at delivery, and
the extent to which postnatal exercises were carried out
may all contribute to risk of prolapse. The strong association
between parity and risk of prolapse that was
observed in this study suggests that study of such
obstetric factors may provide important clues as to how
obstetric care might reduce the risk of prolapse in later
life. A neurophysiological study, for example, demonstrated
that long active second stages of labour and
heavier babies were associated with greater damage to
the pelvic floqr as evidenced by electromyelogram
(EMG) changes than other factors such as forceps
delivery and perineal tears20. There is a need for
epidemiological studies to complement this neurophysiological
approach to the problem.
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