Investigation to Minimize Prolapse Recurrence of the Vagina Using Estrogen
Phase: PHASE4
Conditions: Pelvic Organ Prolapse, Urogenital Prolapse, Vaginal Vault Prolapse, Cystocele, Uterine Prolapse, Vaginal Prolapse, Pelvic Floor Disorders
Sponsor: University of Texas Southwestern Medical Center

 
 
Official title: Investigation to Minimize Prolapse Recurrence Of the 
Vagina using Estrogen (IMPROVE) 
 
NCT number: NCT02431897 
IRB approved date: 05-24-2019 

 
i 
 
INVESTIGATION TO MINIMIZE PROLAPSE RECURRENCE OF THE 
VAGINA USING ESTROGEN (IMPROVE) 
 
A randomized, double-blind clinical trial of conjugated estrogen vaginal cream compared with 
placebo given peri-operatively in 222 postmenopausal women with symptomatic pelvic organ 
prolapse undergoing a standardized transvaginal native tissue surgical repair. 
 
 
 
Principal Investigators:  
 
University of Texas Southwestern: David D. Rahn, MD 
University of Alabama at Birmingham: Holly Richter, PhD, MD 
Women & Infants Hospital of Rhode Island: Vivian Sung, MD, MPH 
 
Data Coordinating Center: 
UT Southwestern/ Dept. of Population & Data Sciences: Linda Hynan, PhD 
 
Version 1.8 
April 15, 2019 
 
 
 
 
Supported by: 
The National Institute on Aging  
R01 AG047290-01A1 
 
 
Study Intervention Provided by Pfizer, Inc.  
 
 
Granted exemption from IND regulations by the FDA, IND #126597 

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TABLE OF CONTENTS 
Page 
PRÉCIS .......................................................................................................................................... v 
Study Title ................................................................................................................................... v 
Objectives ................................................................................................................................... v 
Design and Outcomes ................................................................................................................. v 
Interventions and Duration ......................................................................................................... v 
Sample Size and Population....................................................................................................... vi 
STUDY TEAM ROSTER ............................................................................................................ 1 
Principal Investigator:  ............................................................................................................. 1 
Co-Investigators:  ..................................................................................................................... 1 
PARTICIPATING STUDY SITES ............................................................................................. 1 
1 
Study objectives ..................................................................................................................... 2 
1.1 
Primary Objective ........................................................................................................... 2 
1.2 
Secondary Objectives ...................................................................................................... 2 
2 
BACKGROUND AND RATIONALE ................................................................................ 2 
2.1 
Background on Condition, Disease, or Other Primary Study Focus .............................. 2 
2.2 
Study Rationale ............................................................................................................... 5 
3 
STUDY DESIGN ................................................................................................................... 9 
3.1 
Design Schema (Figure 3) ............................................................................................ 10 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS .......................................... 11 
4.1 
Inclusion Criteria .......................................................................................................... 11 
4.2 
Exclusion Criteria ......................................................................................................... 12 
4.3 
Study Enrollment Procedures ....................................................................................... 12 
5 
STUDY INTERVENTIONS .............................................................................................. 13 
5.1 
Interventions, Administration, and Duration ................................................................ 13 
5.2 
Handling of Study Interventions ................................................................................... 13 
5.3 
Concomitant Interventions ............................................................................................ 14 
5.3.1 Allowed Interventions ............................................................................................... 14 
5.3.2 Required Interventions .............................................................................................. 15 
5.3.3 Prohibited Interventions ............................................................................................ 15 
5.4 
Adherence Assessment ................................................................................................. 15 

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6 
STUDY PROCEDURES .................................................................................................... 17 
6.1 
Schedule of Evaluations ................................................................................................ 18 
6.2 
Description of Evaluations ............................................................................................ 20 
6.2.1 Screening Evaluation ................................................................................................ 20 
6.2.2 Enrollment, Baseline, and/or Randomization ........................................................... 20 
6.2.3 Follow-up Visits........................................................................................................ 22 
6.2.4 Completion/Final Evaluation .................................................................................... 26 
7 
SAFETY ASSESSMENTS ................................................................................................. 26 
7.1 
Specification of Safety Parameters ............................................................................... 27 
7.2 
Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters .... 27 
7.3 
Adverse Events and Serious Adverse Events ............................................................... 28 
7.4 
Reporting Procedures .................................................................................................... 29 
7.5 
Follow-up for Adverse Events ...................................................................................... 29 
7.6 
Safety Monitoring ......................................................................................................... 30 
8 
INTERVENTION DISCONTINUATION........................................................................ 31 
9 
STATISTICAL CONSIDERATIONS .............................................................................. 31 
9.1 
General Design Issues ................................................................................................... 31 
9.2 
Sample Size and Randomization .................................................................................. 32 
9.2.1 Treatment Assignment Procedures ........................................................................... 32 
9.3 
Interim analyses and Stopping Rules ............................................................................ 33 
9.4 
Outcomes ...................................................................................................................... 33 
9.4.1 Primary outcome ....................................................................................................... 33 
9.4.2 Secondary outcomes ................................................................................................. 33 
9.5 
Data Analyses ............................................................................................................... 38 
10 DATA COLLECTION AND QUALITY ASSURANCE ................................................ 40 
10.1 
Data Collection Forms .................................................................................................. 40 
10.2 
Data Management ......................................................................................................... 40 
10.3 
Quality Assurance ......................................................................................................... 41 
10.3.1 
Training ................................................................................................................. 41 
10.3.2 
Quality Control Committee ................................................................................... 41 
10.3.3 
Metrics .................................................................................................................. 41 
10.3.4 
Protocol Deviations ............................................................................................... 41 
10.3.5 
Monitoring ............................................................................................................ 42 
11 PARTICIPANT RIGHTS AND CONFIDENTIALITY ................................................. 43 
11.1 
Institutional Review Board (IRB) Review .................................................................... 43 
11.2 
Informed Consent Forms .............................................................................................. 43 
11.3 
Participant Confidentiality ............................................................................................ 43 
11.4 
Study Discontinuation ................................................................................................... 43 

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12 ETHICAL CONSIDERATIONS ....................................................................................... 44 
13 COMMITTEES................................................................................................................... 44 
14 PUBLICATION OF RESEARCH FINDINGS ................................................................ 44 
15 REFERENCES .................................................................................................................... 45 
 
 

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PRÉCIS 
Study Title  
Investigation to Minimize Prolapse Recurrence Of the Vagina using Estrogen 
(IMPROVE) 
Objectives  
Aim 1: Determine if adjunctive vaginal estrogen given pre- and postoperatively with 
standardized native tissue transvaginal prolapse repair surgery results in improved 
objective and patients’ subjective sense of pelvic organ support, retreatment rate, 
postoperative satisfaction, and quality of life one year postoperatively with continued 
annual surveillance up to 3 years.  
 
Aim 2: Determine if perioperative vaginal estrogen therapy in this same population 
impacts other pelvic floor disorder symptoms.  Specifically, we will quantify the effects of 
vaginal estrogen on symptoms of overactive bladder and urinary incontinence (Subaim 2a), 
sexual function and dyspareunia (Subaim 2b), postoperative cystitis (Subaim 2c), and 
symptomatic vulvovaginal atrophy (Subaim 2d). 
 
Aim 3: Quantify histomorphology and connective tissue homeostasis of the vaginal wall 
in postmenopausal women with symptomatic prolapse undergoing surgical repair with or 
without pre- operative intravaginal estrogen therapy. We will determine the potential 
mechanisms by which local estrogen treatment alters pelvic organ support and quantify the 
effects of vaginal estrogen on synthesis and degradation of extracellular matrix proteins 
and its impact on smooth muscle of the vaginal wall. 
Design and Outcomes   
Design: Randomized, double-blind, placebo-controlled trial of pre- and postoperative 
intravaginal estrogen therapy in 222 postmenopausal women with symptomatic prolapse 
undergoing a standardized surgical repair using native tissue. 
 
Primary outcome: prolapse recurrence as defined by a composite of objective prolapse 
beyond the hymen, subjective/symptomatic prolapse (feeling of a bulge or no change or 
worse on the patient’s global impression of improvement), or retreatment (e.g., reoperation 
or pessary use) assessed 1 year postoperatively. Time to failure will be compared in the 
two groups. 
 
Important secondary outcomes assessing for changes in overactive bladder and urinary 
incontinence symptoms will be made by comparing symptoms (validated questionnaires) 
from Baseline to Pre-op/time of surgery. Aim 3 (see above, histomorphology, connective 
tissue studies) will be assessed from full thickness anterior apical vaginal wall biopsies 
taken at the time of surgery.  

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Interventions and Duration  
Intervention: 1g conjugated estrogen (CE) cream (Premarin®, Pfizer Inc.) given nightly 
for 2 weeks then twice-weekly to complete planned 6-8 weeks (5 weeks minimum) therapy 
before a standardized uterosacral or sacrospinous ligament suspension transvaginal 
prolapse repair surgery. Those with a uterus will undergo concomitant total vaginal 
hysterectomy first. Twice-weekly CE cream application is then resumed upon discharge 
and continued for 1 year postoperatively.  
Comparator: placebo vaginal cream, same schedule 
Duration: The primary outcome of prolapse recurrence is assessed at one year 
postoperatively with continued surveillance of participants until 3 years postoperatively. 
Sample Size and Population  
Total sample size: N=222; 111 per treatment group 
 
Target population: Women ≥48 years and at least 1 year postmenopausal (or status post 
BSO) with vulvovaginal atrophy; no oral, vaginal, or transdermal medication containing 
estrogens (including selective estrogen receptor modulators, or SERMs), androgens, or 
progestins within 8 weeks of screening; with symptomatic pelvic organ prolapse (≥stage 2 
anterior/apical prolapse) fit for elective transvaginal native tissue repair will be included. 
Exclusions are BMI >35, current tobacco or steroid use, any other medications affecting 
vaginal milieu, vaginal infection, prior vaginal apical repair surgery or surgery using mesh 
for prolapse, and contraindications to estrogen therapy (e.g., stroke, prior 
thromboembolism, estrogen-responsive tumor, postmenopausal vaginal bleeding). 
 
Other: randomization will be stratified by site (3 clinical sites participating), hysterectomy 
status, and duration since menopause (<10 and ≥10 years). The randomization lists will be 
distributed to each site’s research pharmacy. Outcome assessors and patients will be 
blinded to assignment. 

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STUDY TEAM ROSTER & OTHER PARTICIPATING STUDY SITES: 
 
David D. Rahn, MD 
Principal Investigator (PI) 
  
Associate Professor, 
Dept. Ob/Gyn, 
University of Texas 
Southwestern Medical 
Center (UTSW) 
5323 Harry Hines Blvd. 
Dallas, TX 75390-9032 
(T) 214.648.6430 (F) 214.648.5697 
david.rahn@utsouthwestern.edu  
R. Ann Word, MD  
Co-Investigator, Role: Basic 
Scientist (Aim 3 oversight) 
Professor, Dept. Ob/Gyn, 
UTSW 
ruth.word@utsouthwestern.edu 
(T) 214-648-3825 
Joseph Schaffer, MD  
Co-Investigator, Role: Clinician/ 
patient recruitment/ study 
oversight with PI 
Professor, Dept. Ob/Gyn, 
Chief of Gynecology, 
UTSW 
joseph.schaffer@utsouthwestern.edu 
Linda Hynan, PhD  
Biostatistician, Role: Data 
coordinating center oversight/ 
statistical support/ preparation of 
reports to DSMB 
Professor of Biostatistics, 
Dept. Population and 
Data Sciences, UTSW 
linda.hynan@utsouthwestern.edu 
(T) 214-648-2685 
Holly Richter, PhD MD  
Sub-Site PI 
 
Professor, Dept. Ob/Gyn,  
University of Alabama 
at Birmingham 
619 South 19th St, 176F Ste. 10382 
Birmingham, AL 35249-7333 
(T) 205.934.1704 
(F) 205.975.8893 
hrichter@uabmc.edu 
Vivian Sung, MD MPH  
Sub-Site PI 
 
Professor, Dept. Ob/Gyn,  
Women & Infants 
Hospital of Rhode 
Island/ Brown Univ. 
101 Dudley St. 
Providence, RI 02905-2499 
(T) 401.274.1122, ext. 8740 
(F) 401.453.7992 
vsung@wihri.org 
 
 
 

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1.1 Primary Objective 
Determine if the experimental treatment (adjunctive vaginal estrogen given pre- and 
postoperatively with standardized native tissue transvaginal prolapse repair surgery) results 
in improved objective and patients’ subjective sense of pelvic organ support, retreatment 
rate, postoperative satisfaction, and quality of life one year postoperatively.  
1.2 Secondary Objectives 
• Determine how perioperative vaginal estrogen therapy in this same population impacts 
other pelvic floor disorder symptoms.  Specifically, we will quantify the effects of 
vaginal estrogen on… 
(a) symptoms of overactive bladder and urinary incontinence  
(b) sexual function and dyspareunia  
(c) postoperative cystitis  
(d) symptomatic vulvovaginal atrophy 
 
• Quantify histomorphology and connective tissue homeostasis of the vaginal wall in this 
same population and determine the potential mechanisms by which local estrogen 
treatment alters pelvic organ support and quantify the effects of vaginal estrogen on 
synthesis and degradation of extracellular matrix proteins and its impact on smooth 
muscle of the vaginal wall. 
2 
BACKGROUND AND RATIONALE  
2.1 Background on Condition, Disease, or Other Primary Study Focus 
Pelvic organ prolapse (POP) is important from individual and public health 
perspectives. Although some degree of loss of vaginal or uterine support is present in most 
adult women, 3-6% have descent to the hymen or beyond, which corresponds to clinically 
significant disease and bother for patients.1,2 POP is the most common reason for 
hysterectomy among postmenopausal women and is an indication for more than 338k 
inpatient surgical procedures each year.3 The lifetime risk of surgery for POP and stress 
urinary incontinence is 20%, and for POP surgery alone, 13%.4 There are substantial social, 
psychological and financial implications for women with POP.5-7 For society, the estimated 
annual direct costs are more than $1 billion (for 226k surgeries)8 and costs for POP 
surgeries in coming decades are expected to grow at twice the rate of population growth 
due to our aging population.9  
 
Aging is a known risk for POP. The etiology of POP is multifactorial, and 3 risks are 
well-established: vaginal delivery, aging, and obesity.10 Among ambulatory women 
presenting for yearly examination, the relative prevalence of POP increased by 40% with 
each decade of life.1 As our population ages, projections for 2050 are that the number of 
US women with prolapse will increase 46% from 3.3 to 4.9 million, underscoring the 
substantial burden that POP represents for our healthcare system.11 
 
Prolapse progression and recurrence after primary surgical repair are common in 
older women. While there are limited data describing the natural history of POP 

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progression, a single-site observational study of women over 2-8 years from within the 
Women’s Health Initiative (WHI) reported incidence of grades 1-3 cystocele (i.e. bladder 
prolapse from just inside to just outside the hymen) to be 9.3/100 women-years and 5.7/100 
women-years for rectocele.12 Progression from grade 1 (generally asymptomatic) to grades 
2 to 3 (i.e. symptomatic) prolapse was seen in 9.5% of patients with cystoceles and 14% of 
those with rectoceles. Some remissions occurred for grade 2-3 cystoceles and rectoceles, 
but, of note, there were no observed remissions for women with grade 2 or 3 uterine/apical 
prolapse. Another study from the WHI by Bradley et al described 1-year and 3-year 
incidence rates of prolapse at the hymen or beyond as 26% and 40%, respectively.13 
Importantly, older parous women were more apt to develop new or progressive prolapse 
than to regress. 
 
Traditionally, reconstructive surgeries for anterior and apical vaginal prolapse 
are performed transvaginally using native tissue (e.g. using uterosacral or sacrospinous 
ligaments as fixation points), although transvaginal or abdominal/ laparoscopic approaches 
with augmentation by synthetic graft materials are also common. Reoperation for recurrent 
prolapse is common, and rates are highest in the traditional vaginal surgery group.14 
Denman et al reported 17% of patients needing repeat operations within 10 years, which 
likely represents an underestimate of the true rate.15 Indeed, in a cross-sectional analysis of 
women in a private HMO in the Northwest undergoing POP or incontinence surgery, 29% 
of cases were reoperations.16 
 
New surgical strategies may improve the efficacy of repair but with new risks. To 
address these unacceptably high failure and reoperation rates, surgical techniques have 
evolved; the addition of synthetic transvaginal mesh was first approved by the FDA in 
2004. Since then, hundreds of thousands of mesh systems have been implanted, in 
particular for recurrent or advanced prolapse.17 While it appears that mesh placed 
transvaginally to augment prolapse repairs may decrease the risk of recurrent objective 
anterior vaginal wall prolapse18-20, there are significant trade-offs, including risks of 
visceral and vaginal erosion of mesh, chronic granulation tissue with discharge/drainage, 
de novo pain, worsening stress incontinence, and dyspareunia.20-23 Mesh exposure has 
become a significant problem requiring surgical excision in 7-10% of cases.20,24 Although 
synthetic mesh placed abdominally or laparoscopically for sacral-colpopexy (i.e. lifting the 
vagina to the sacrum via mesh) is generally considered to have an acceptable risk-benefit 
ratio, compared to vaginal procedures, there is longer operating time, increased cost, and a 
non-negligible risk of serious complications. All graft materials for prolapse repairs are 
under increased scrutiny, highlighted by recent advisories from the FDA warning about the 
risks associated with mesh use in pelvic surgery.24-26 
 
Summary: Given an aging population with increasing prevalence of POP, more women 
will require surgical management. Procedures utilizing graft materials, particularly if 
introduced transvaginally, are associated with complications that may represent an 
unacceptable risk for many women. Therefore, there is an urgent need to identify adjuncts 
to native tissue prolapse repair that may prevent or minimize recurrent disease. 
 
The utility of estrogen in POP management is uncertain.  Both basic and clinical 
investigations indicate that estrogen plays an important role in the function of supportive 

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connective tissues of the pelvic floor. Estrogen and progesterone receptors have been 
identified in the nuclei of connective tissue and smooth muscle cells of both the levator ani 
stroma and uterosacral ligaments.27,28 The ratio of collagen I (generally consisting of well-
organized fibers and associated with ligamentous tissue) to collagen III and IV (more 
common in loose areolar tissue) is decreased in pelvic connective tissues of 
postmenopausal women not on hormone replacement therapy.29 This relative decrease in 
well-organized dense collagen is believed to contribute to weakening of vaginal tensile 
strength thereby leading to increased susceptibility to anterior vaginal wall prolapse. 
Further, estrogen is thought to play a role in inhibiting expression of collagen- and elastin-
degrading proteins in the vagina and fibroblasts of uterine supportive tissue.30,31 In 
contrast, other research suggests that matrix metalloproteinases (MMPs) are upregulated 
by estrogen and that estrogen-induced suppression of tissue inhibitors of 
metalloproteinases (TIMPs) is involved in negative effects on the pelvic floor.32,33 
Clinical research regarding the effect of systemic hormone therapy on prevention 
or treatment of POP has also led to contradictory findings. Different estrogen receptors in 
the urogenital tract have been studied with various selective estrogen receptor modulators 
(SERMs). A meta-analysis of the effects of raloxifene (a SERM used for osteoporosis 
treatment and prevention) identified an apparent protective effect on the pelvic floor with 
reduction in the need for prolapse surgery at a 3-years (OR 0.50, 95% CI 0.31-0.81).34 
Importantly, however, the total number of women having prolapse surgery was small; there 
was no standardized evaluation for POP in any study; and the baseline obstetrical histories 
were not known or reported. Two ancillary studies from the WHI found no difference 
between women treated with systemic estrogen and progesterone compared with those 
treated with placebo in terms of percent of participants with prolapse ≥ stage 2, and duration 
of hormone therapy did not appear to affect rate of prolapse.7,35 It should be noted, however, 
that progesterone often opposes the effect of estrogen in the female reproductive tract. A 
case-control study by DeLancey et al examining levator ani defects in women with and 
without prolapse noted higher rates of prolapse in women using hormone therapy.36 The 
most recent Cochrane review of estrogens for the treatment or prevention of POP suggests 
that evidence is too limited and that there is a need for studies randomizing to estrogen 
preparations for the “prevention and management of POP, particularly as an adjunctive 
treatment for women using pessaries and also before and after prolapse surgery.”37 
 
The role of vaginal estrogen in other PFDs is better characterized. As both the lower 
female genital and urinary tracts arise from the primitive urogenital sinus, it is not 
unexpected that estrogen receptors are found in tissues of the vagina, urethra, bladder, and 
surrounding pelvic floor musculature.38-40 Contrary to the limited information of estrogen’s 
effects on POP, the effect of estrogen on urinary incontinence in postmenopausal women 
is more understood, although effects differ depending on systemic vs. local estrogen 
delivery.41 Six trials of systemic estrogen demonstrated worse incontinence (urge, stress, 
or mixed) compared with placebo, in both systemic conjugated estrogens alone (RR 1.32, 
1.17-1.48) or combined with progesterone (RR 1.11, 1.04-1.18). However, with local 
application of estrogen, incontinence rates improved (RR 0.74, 0.64-0.86), and urinary 
urgency (RR 0.38, 0.15-0.99) and frequency also improved. A recent randomized trial of 
local estrogen vs. an oral anticholinergic medication (oxybutynin) for treatment of 
overactive bladder in postmenopausal women demonstrated similar effectiveness in 

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decreasing number of daily voids and improvements in disease-specific quality of life.42 
Of note, the Cochrane review’s summaries of improvements with local estrogen were based 
on just 2-4 trials, and further study was recommended. Effects on stress urinary 
incontinence are not as well-characterized, but local estrogen has been shown to decrease 
the pulsatility index in the urethral vascular network (indicating greater blood flow) and 
improve subjective stress incontinence bother in 60% of patients.43 
Local intravaginal estrogen in postmenopausal women by any delivery system 
(creams, tablets, estrogen-containing rings) is known to decrease vaginal pH, increase 
blood flow, improve tissue compliance, and promote vaginal cell maturity.44 Reviews and 
studies of other pelvic floor disorders commonly linked with loss of estrogen and urogenital 
atrophy observed in postmenopausal women (dryness, pruritus, pain/ dyspareunia45-47, 
recurrent cystitis48,49) generally demonstrate improvement in symptoms and quality of life 
using local estrogen.44,46,50,51 However, these conditions are not well-characterized in 
women also presenting with POP or for perioperative complaints such as early 
postoperative cystitis. 
 
Perioperative use of vaginal estrogen is inconsistent & patient adherence is poor. 
Although some gynecologists may anecdotally recommend pre- and postoperative vaginal 
estrogen empirically for postmenopausal patients undergoing surgery, there are few studies 
that directly examine local estrogen use and perioperative outcomes.52,53 Estrogens may 
affect cutaneous wound healing by modulating cytokine expression, inflammatory 
response, and matrix deposition. Stimulation of angiogenesis and regulation of proteolysis 
may accelerate re-epithelialization.54,55 These effects have been studied in dermatologic 
but not gynecologic populations. A study that provides compelling evidence to recommend 
perioperative vaginal estrogen use will provide a strong incentive for women to remain 
adherent to vaginal estrogen. Otherwise, anecdotal or empiric prescriptions are likely to be 
unsuccessful because 9% of menopausal women receiving a vaginal estrogen prescription 
never fill it, and discontinuation occurs by most after just 3 months.56,57 
 
Summary: Menopause and loss of estrogen contribute to the decompensation of pelvic 
organ support. Overall, basic science and clinical investigations clearly demonstrate an 
important role for reproductive hormones in the maintenance of connective tissues and the 
extracellular matrix necessary for pelvic visceral support and healthy urogenital tract 
function, but the precise role for vaginal estrogen in POP management is uncertain. A 
scientifically rigorous study examining the impact of pre- and postoperative vaginal 
estrogen on maintenance of support after surgical repair of POP is needed and may provide, 
for the first time, evidence for a safe, low-cost adjunct for prevention of recurrent disease.  
2.2 Study Rationale 
2.2a Preliminary Studies: Studies in preclinical animal models (mice, guinea pigs, and 
rats) indicate that estrogen is important in elastic fiber renewal and collagen homeostasis 
in the fibromuscular vaginal wall. In this protocol, there is the suggestion of a unique 
adaptation to synthesize and assemble new elastic fibers allowing the vagina to respond to 
local estrogen treatment with increased synthesis of collagen and elastic fibers. To follow 
are summaries of studies in mice, guinea pigs58, rats, and a pilot study in humans59 that 
provide support and a rationale for the proposed specific aims. 

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Mice: Estrogen alters vaginal epithelium, muscularis, protease activation, and matrix 
synthesis. Mice were ovariectomized to study the effect of menopause and later estrogen 
replacement (added after 14d) on proteins important in elastic fiber cross-linking, i.e. lysyl 
oxidase (LOX), lysyl oxidase-like 1 (LOXL1), and fibulin-5 (FBLN-5), and elastogenesis 
in the vaginal muscularis. The data indicate that, like bone, early after menopause there is 
rapid induction of protease activity and loss of matrix proteins. Thereafter, a slower decline 
in matrix synthesis results in a thinner and perhaps, even less resilient organ. The loss of 
both vaginal epithelial and muscularis thickness was fully reversed by estrogen 
replacement. This suggests that the baseline characteristics of the vaginal matrix at the time 
of menopause, together with the rate and severity of estrogen withdrawal, may compromise 
the ability of the vagina and its suspensory connective tissue to maintain pelvic organ 
support after menopause and with aging. 
 
Guinea pigs: Systemic estrogen alters wound healing of the vaginal wall.58 Nulliparous 
ovariectomized guinea pigs treated with estradiol (or vehicle) replacement were used to 
determine effects of estrogen on biomechanical properties, LOX, collagen content, and 
histomorphology of the vagina with or without surgical injury to the perineum. Estradiol 
resulted in (i) significant growth, increased smooth muscle, and increased thickness of the 
vagina, (ii) increased distensiblity without compromise of maximal force at failure, and 
(iii) increased total and cross-linked collagen. The results suggest prolonged estradiol-
induced increases in LOX and collagen crosslinks may sustain a matrix environment 
optimizing long term wound healing in the vagina. 
 
Rats: Local estrogen cream improves vaginal function and connective tissue. The 
effects of systemic and local estrogen on (i) uterine and vaginal weight, (ii) serum estradiol 
(E2) levels, (iii) collagen content and expression of proteins involved in collagen assembly, 
and (iv) biomechanical properties of the vaginal wall were studied using ovariectomized 
rats treated with systemic estradiol, vaginal conjugated estrogens cream, or vaginal placebo 
cream. Vaginal estrogen treatment increased total and cross-linked collagen content and 
markedly stimulated collagen mRNA expression in an inverse dose-effect relationship. The 
results suggest that high-dose vaginal estrogen results in down-regulation of ERα and loss 
of estrogen-induced increases in vaginal collagen. Low-dose vaginal estrogen treatment 
resulted in significant vaginal growth and increased distensiblity without uterine 
hyperplasia.  
 
Humans: Effects of Preoperative Estrogen Treatment (the “PET” study) on 
connective tissues of the pelvic floor59: Results from these preclinical animal models, 
therefore, led to a pilot trial examining the effects of vaginal estrogen on the biochemistry, 
molecular profile, & histology of the vaginal wall. 
Population: 30 women ≤10yr post-menopausal & ≥stage 2 symptomatic anterior or apical 
prolapse (i.e., leading edge of bulge to the hymen or beyond) planning repair involving 
hysterectomy. Exclusions: BMI >35kg/m2, current tobacco or steroid use, vaginal 
infection, and contraindications to estrogen therapy.  
Intervention: Participants were randomized to 6 weeks of preoperative vaginal estrogen 
(Premarin® cream 0.625mg/gm, 1gm applied nightly for 2 weeks then 2 times per week) 

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7 
or identical placebo cream. A standardized full-thickness biopsy was obtained from the 
apical anterior vaginal wall at the time of surgery. 
Outcomes: Vaginal biopsies were analyzed for histological differences in tissue thickness 
and composition. Assays were also performed to assess mRNA (quantitative PCR), cross-
linked collagen (hydroxyproline assays), collagen types I and III (immunoblots), and 
matrix metalloprotease (MMP) activity (zymography).  Serum estrone (E1) and estradiol 
(E2) were assessed at baseline and the day of surgery using highly sensitive liquid 
chromatography-tandem mass spectrometry assays60, and surgical specimens were also 
examined for endometrial & myometrial thickness and pathology. 
Results: Demographics of Estrogen & Placebo groups were similar with no significant 
differences in age, BMI, parity, baseline prolapse, race/ethnicity, or route of hysterectomy. 
Two patients per group did not have surgery (unrelated to study medications) and were not 
analyzed in the final comparisons as they had no tissue biopsy. More patients in the 
Estrogen group (4 of 13) were non-adherent compared to Placebo (0 of 13), P=0.030, as 
assessed by a composite of patient diaries and tube weights at baseline and at surgery.  
Histologic changes & collagen synthesis: Analyzed per-protocol and in those with 
sufficient tissue for analysis (Estrogen=8; Placebo=12), epithelial thickness was increased 
1.8-fold in the Estrogen group (551±45 vs. 314±43 μm, P=0.002). Consistent with our 
studies in the 3 animal models, 
thickness of the muscularis was 
increased 2.7-fold (7571 vs. 2807 
μm, P=0.088). Levels of collagen 
types 1α1, 1α2, & 3α mRNA were 
increased 6.0-, 1.8-, & 2.5-fold in 
the vaginal muscularis of the 
Estrogen group (p<0.05 for 1α1 & 
1α2) 
(Fig.1A). 
Immunoblot 
analysis was completed in 4 
patients in each group with 
sufficient 
tissue 
for 
protein 
analysis.  Collagen type Ia protein 
increased 9-fold in the muscularis 
from 
women 
treated 
with 
Estrogen (P=0.012) (Fig. 1B). In 
contrast, differences in collagen 
III protein were not significant 
(P=0.27). Although similar in the 
vaginal mucosal layer, total cross-
linked 
collagen 
content 
as 
determined by hydroxyproline 
assays was increased 3.2-fold in 
the 
muscularis 
of 
Estrogen 
patients (P=0.10). These studies, therefore, indicate that collagen type I is preferentially 
enhanced by vaginal estrogen treatment and that the increase in collagen content is 
localized to the underlying fibromuscular layer. 
 
Fig. 1.  Effect of vaginal estrogen on collagen types I and 
III in the vaginal muscularis.  A.  Levels of Col1α1, 1α2, 
and 3α mRNA in tissues from women treated with Placebo
(n=12) or Estrogen (n=8).  Immunoblot analysis (B) and
densitometry (C) of collagen type I and III (n=4 per group).
*P < 0.05; **P < 0.01  

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
8 
Collagenase and elastolytic activity: Since vaginal epithelium is known to be a rich 
source for protease inhibitors61, the mucosa was evaluated for expression of these 
molecules. Although highly expressed in vaginal mucosa, mRNA levels of 3 serine 
protease inhibitors (elafin, secretory leukocyte protease inhibitor, and α1-antitrypsin) and 
two MMP inhibitors (TIMP1 and 2) were similar between Estrogen and Placebo.  
Interestingly, however, MMP12 mRNA (aka human macrophage elastase, a protease 
important 
for 
collagen 
degradation) 
was 
suppressed in the vaginal 
mucosa 
from 
women 
treated 
with 
Estrogen 
compared to Placebo. The 
most striking effects of 
Estrogen were found using 
quantitative 
gelatin 
zymography 
in 
which 
MMP9 activity was down-
regulated 6-fold in the 
mucosa and 4-fold in the 
muscularis (P=0.02) in 
Estrogen-treated 
women 
(Fig. 2). 
 
Tolerability & Safety: There were no differences in thickness of endometrium (1.8±1.2 
vs. 1.4±0.7 mm) or myometrium (1.7±0.6 vs. 2.2±1.6 cm) for Estrogen vs. Placebo, and no 
cases of proliferative, secretory or hyperplastic endometrium. Consistent with menopausal 
norms, serum estrone and 17β-estradiol were low and did not differ among the two groups. 
Median (IQR) postoperative anterior wall prolapse stage 6mo postop was 0.5 (0.5,0.8) vs. 
1 (0,1.3), P=0.56, in Estrogen vs. Placebo. However, this pilot study was not intended nor 
powered to examine anatomic endpoints, and the study drug was not administered 
postoperatively. 
 
Summary: Preoperative local vaginal estrogen application results in increased thickness of 
both the vaginal epithelium and muscularis in adherent postmenopausal women with 
prolapse. Increases in collagen type I mRNA and protein were disproportionate to that of 
collagen type III with type I-enriched muscularis. Further, there was down-regulation of 
MMP1, MMP9 and MMP12 in the vaginal wall with no change in expression of several 
protease inhibitors. Taken together, findings from this pilot trial suggest that six weeks of 
preoperative vaginal estrogen in postmenopausal women with prolapse may improve the 
substrate for suture placement at time of repair while mitigating surgical induction of 
several degradative enzymes, thereby improving long-term maintenance of connective 
tissue integrity in the pelvic floor. 
 
2.2b Rationale for use of CE cream (vs. other vaginal estrogens): While adherence to 
prescription medications is often poor and hindered by increasing age, minimally-
symptomatic conditions, polypharmacy, and labor-intensive therapy such as application of 
Fig. 2.  Vaginal estrogen inhibits MMP-9 activity.  Quantitative
gelatin zymography was conducted in vaginal muscularis (A) or
mucosa (B) from women treated with placebo or estrogen vaginal
cream.  Bars represent mean ± SEM 
1   2   3    4    5   6   7    8    9   10 11  12 
Placebo
Estrogen
MMP-9
proMMP-2
MMP-2
A. 
MMP-9
proMMP-2
MMP-2
Placebo
Estrogen
Muscularis
Mucosa
B. 
MMP-9 Activity
(R.U./mg protein)
0
40
80
120
160
Placebo
Estrogen
*P = 0.02
MMP-9 Activity
(R.U./mg protein)
0
15
30
45
60
Placebo
Estrogen
*P = 0.06

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
9 
a vaginal cream62, in the setting of other rigorous clinical trials, exceptionally good 
adherence rates have been observed: CE cream 2x/wk discontinuation over 1 year was just 
9.8% in a recent study.63 Theoretically, adherence could be improved over cream using an 
estradiol ring (Estring®), which is replaced every 3 months, but users are sometimes 
bothered by difficulty with ring removal, concern over vaginal infection risk, bother with 
partner feeling the ring, or difficulty with insertion.64 Further, a trial that randomized 
women undergoing reparative surgery immediately postoperatively to 12 weeks of vaginal 
estradiol or placebo rings found increased granulation tissue attributed to a foreign body 
reaction/ inflammation with the placebo (12 of 21) compared to the estradiol ring (3 of 22), 
P<0.01.53 Another alternative, the vaginal estradiol tablet (Vagifem®), is only available as 
a 10 μg tablet, which is not equivalent to the 1g CE cream demonstrated as effective in 
matrix synthesis and decreased protease activity in the pilot study referenced above.59 In 
addition, severely atrophic patients sometimes report failure of the tablet to dissolve and/or 
the tablet falling out with the emergence of the POP. Finally, there are other potential 
benefits stemming from the unique “Ring B” unsaturated equine estrogens, including 
inhibition of LDL and HDL oxidation and apoptosis in neurons.65 
 
2.2c Rationale for timing & duration postoperative CE cream: Prior studies using a 
murine model of menopause demonstrated a “burst” in pro- and active MMP9 activity for 
1-7d after withdrawal of estrogen; LOX and LOXL1 mRNA were simultaneously decreased 
as were overall protein content and mature elastic fibers, indicating that remodeling occurs 
rapidly with withdrawal of estrogen (see 2.2a Mice above). Hence, it is a priority to resume 
local estrogen as soon as safely feasible after prolapse repair and to continue its use until 
mature scar formation has completed. Completion of connective tissue remodeling after 
wound healing occurs from 21d up to 1 year after injury.66,67 This duration is necessary for 
collagen III to be replaced with stronger collagen I.66 Therefore, this protocol calls for 
continued estrogen therapy (avoiding the potential consequences of withdrawal) 
throughout this remodeling process. 
3 
STUDY DESIGN 
DESIGN: Randomized, double-blind, placebo-controlled trial (See Fig.3 “Design 
Schema”) 
 
POPULATION: Women ≥48 years and at least 1 year postmenopausal (or status post BSO) 
with vulvovaginal atrophy [no oral, vaginal, or transdermal medication containing 
estrogens (including SERMs), androgens, or progestins within 4 weeks of screening] with 
symptomatic POP (≥stage 2 anterior/apical prolapse) fit for elective transvaginal native 
tissue repair will be included. Exclusions are BMI >35, current tobacco or steroid use, any 
other medications affecting vaginal milieu, vaginal infection, prior vaginal apical  
repair surgery or surgery using mesh for prolapse, and contraindications to estrogen therapy 
(e.g., stroke, prior thromboembolism, estrogen-responsive tumor, postmenopausal vaginal 
bleeding).  
 
INTERVENTION: Conjugated estrogens (CE) cream 0.625mg/g (Premarin®) 1g or 
identical placebo, inserted vaginally nightly for 2 weeks, then twice weekly for 4-6 more 
weeks before surgery (i.e. planned  6-8 weeks total of preoperative use, 5 weeks minimum). 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
10 
CE (or placebo) cream is then resumed before hospital discharge and continued 2-times 
per week for one year. The planned surgery will be standardized across sites, as has been 
achieved previously68,69 (see description below).  
 
Figure 3. Design Schema 
 
 
 
 
 
 
 
                              
 
# 3 validated short-form (in English and Spanish) Pelvic Floor Disorder (PFD) questionnaires (already used as 
standard of care at patient intake): PFDI-2073, PFIQ-773, PISQ-IR74 plus a 6-question survey of vaginal atrophy 
symptomatology75, a general QoL instrument (SF-12), and a body image questionnaire. Total estimated time 
burden for participants: 45 min 
 
† Optional full thickness vaginal wall biopsy from anterior apical vagina; this will be shipped to UTSW in buffered 
solution (RNAlater®) for histologic assessment & qPCR for mRNA testing. Tissue collected locally at UTSW 
will also be analyzed by zymography (protease enzyme activity), immunoblotting, and hydroxyproline assay for 
cross-linked collagen content.  
 
* At these time points at 3 and 9-mo postoperatively, new study drug will be shipped (Fed-Ex) to the patient (or 
she may choose to present to the research clinic to collect a new tube of study drug). Coordinator calls are also 
planned at these times to remind patients of new study cream coming and/or to confirm receipt. 
 
Questionnaires & Exam: 
 
 
 
 
 
 PFD questionnaires# 
X 
X   
 
X 
X 
X 
 PGI-S70 (symptom 
severity) 
X 
  
 
X 
X 
X 
 PGI-I70 (symptom 
improvement) 
 
  
 
X 
X 
X 
 POP-Q prolapse 
exam71 
X 
  
        X 
X 
X 
X 
Study drug dispensed: 
X(1) 
 X(2) 
 
X*(3)    X(4)    X*(5)         
 
Document tube 
weight** 
X(1) 
 X(1,2) 
 
X*(3)   X(2-4) X*(5)   X(5) 
 
Specimens & biopsies: 
 
  
 
 
 
 
 Vaginal maturation 
index72 
X 
 X 
 
 
X 
 
 Serum estrone & 
estradiol60 
X 
  
 
 
X 
 
 Whole blood, banked 
for later DNA/ genetic 
assessment (optional) 
X 
  
 
 
 
 
 Vaginal wall biopsy† 
 
 X† 
 
 
 
 
Baseline 
assessment & 
randomization, 
N=222 
CE cream 
N=111 
Placebo 
N=111 
>5wk 
Pre-Op Visit 
Surgery/inpatient 
4wk 
1mo Postop 
Check 
6mo Postop 
Check 
12 mo Postop 
Check: PRIMARY 
OUTCOME 
18p,24,30p,36-mo 
follow-up 
Study medication continued 2x/week 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
11 
** At these times of study cream dispensing, new and used tube weights will be documented. For example, at 
time of the 6 mo postoperative check, spent tubes #2 and #3 (which were given at time of surgery/ hospitalization 
and Fed-Ex’ed 3mo postop, respectively) are collected and weighed and the new tube #4 is weighed before being 
dispensed to the patient. Weight of new tubes may be recorded in the Investigational Drug Services pharmacies 
or in clinic. 
 
p At these times 18 and 30-mo postoperatively, these are phone call “visits” only with no questionnaires or exam. 
However, the coordinator will phone the participant to query and document: (a) if she has symptoms of a bulge 
or, “something falling out that you can see or feel in your vaginal area”; (b) she has had treatment for pelvic organ 
prolapse since the last visit date; (c) she is experiencing new medical problems or complications; (d) she has been 
hospitalized, had surgery, been to the emergency department, or visited a doctor for urologic or gynecologic 
conditions since the last visit date; and (e) she has had any change in her medications. A reminder of the next in-
person study visit is also given.  
 
Randomization & Blinding: SAS V9.3 will be used to generate stratified randomization 
lists using a permuted block factor of size 4 and 6. Patients will be stratified by site, 
hysterectomy status, and duration since menopause (<10 & ≥10 years). The randomization 
lists will be distributed to each site’s research pharmacy. Outcome assessors and patients 
will be blinded to assignment.  
 
Standardization of surgical procedure: All patients will undergo either a uterosacral 
ligament suspension (“USLS”) similar to that described by Shull76 or a unilateral 
sacrospinous ligament fixation (“SSLF”) in the same fashion described previously68 as an 
inpatient surgical procedure under general anesthesia; these will align with a prior NICHD-
sponsored Pelvic Floor Disorders Network (PFDN) surgical trial68 with agreement on 
placement and type of sutures: if USLS, 1-2 permanent sutures and 1 delayed absorbable 
suture are placed bilaterally (i.e., 4-6 total) beginning at or above the level of the ischial 
spine, with the delayed absorbable suture caudad and the permanent monofilament 
suture(s) ~1 cm cephalad. If the SSLF is selected, 2 permanent and 2 delayed absorbable 
sutures (4 total) are placed unilaterally in the sacrospinous ligament. Based on level I 
evidence, neither USLS nor SSLF is superior to the other for anatomic, functional, or 
adverse event outcomes.69 Participating study surgeons must have performed ≥20 of each 
vault suspension procedure with ≥5 in the 12 months before subject enrollment. 
Anterior/posterior colporrhaphies, vaginal hysterectomy, and midurethral slings are 
allowed but not transvaginal mesh for prolapse. 
4 
SELECTION AND ENROLLMENT OF PARTICIPANTS  
Participants (N=222) in this trial must be postmenopausal women with symptomatic pelvic 
organ prolapse (POP). Eligible patients must be suitably healthy to undergo elective, major 
surgery. To be considered post-menopausal, women will need at least one year without 
menses or be surgically menopausal (i.e. status-post bilateral oophorectomy). Anticipated 
age range of participants will be from 48 years (the minimum allowed) to mid 70s, although 
there is not a strict age limit. Complete inclusion and exclusion criteria are summarized 
below. 
4.1 Inclusion Criteria  
• Postmenopausal, meeting criteria a, b, c, or d:  
a. Still with uterus and no menses for >1 year 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
12 
b. Status-post bilateral oophorectomy (i.e., surgically menopausal) 
c. Status-post hysterectomy (with or without oophorectomy) and >55 years 
d. Vaginal pH ≥5 if ≤55 years and status-post hysterectomy but still with one or 
both ovaries 
• Minimum age: 48 years 
• Symptomatic apical and/or anterior vaginal wall prolapse, stage 2 or greater 
• No estrogen or progesterone replacement within the last month (may come off 
current treatment, i.e. wash out, to join the study) 
• Medically fit for elective surgery 
• Physically able to apply/insert the study drug 
• Available for clinic follow-up for minimum 1 year 
4.2 Exclusion Criteria  
• Concurrent use of steroid creams for other indications (e.g. lichen sclerosis) 
• BMI >35 kg/m2 
• Recent history (within last month) of vaginal infection or vaginitis 
• Contraindications to estrogen therapy (e.g. spontaneous DVT, stroke, breast or 
endometrial/ hormone-responsive cancer, genital bleeding of unknown cause) 
• History of connective tissue disease 
• Any estrogen, progesterone, SERM, or other medication impacting vaginal 
milieu, by any route (oral, transdermal, subdermal/ implantable, intravaginal, 
intrauterine); may come off current treatment (>1 month), i.e. wash out, to join 
the study 
• History of vaginal irradiation 
• Allergy to Premarin® or its constituents 
• Prior apical repair or use of mesh for prolapse repair 
• Current tobacco use 
4.3 Study Enrollment Procedures  
Experience from past clinical trials at each of the participating sites is that recruitment 
generally has not required special advertisements or alterations in existing referral patterns. 
Eligible patients undergo examination and evaluation for treatment in specialty 
urogynecology (rather than general gynecology) clinics at each site: UT Southwestern 
(UTSW), University of Alabama at Birmingham (UAB), and Brown University/ Women 
and Infants Hospital (WIH) of Providence, RI. The Research Coordinator nurse will review 
chief complaints and referral notes of new/ referred patients to screen for eligible study 
participation. A Screening Log will be maintained by the Research Coordinator or PI at 
each site to document identification of subjects who enter pretrial screening and reasons 
for ineligibility and for non-participation of eligible candidates. Weekly team research 
meetings also serve to remind clinic providers (residents, fellows, nurse practitioners, and 
faculty) of inclusion/exclusion criteria and to screen for eligible patients that may benefit 
from this trial. 
 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
13 
Involvement of vulnerable populations: Fetuses, neonates, pregnant women, children, 
prisoners, and institutionalized individuals are not involved in this research protocol. 
 
Consent procedure: After confirmation of study eligibility, potential subjects will be 
approached by the Research Coordinator, PI, or other study personnel (Co-Investigators) 
to describe the study in detail and obtain an informed consent from the patient. Patients 
will be afforded ample time to ask questions and may even take home study literature for 
review to return later for consent and completion of “Baseline” study evaluations. Each 
participating clinical site has access to in-person and telephone (i.e. “Language Line”) 
interpreter services should patients benefit from/ prefer study description in a language 
other than English. A witness will be required to co-sign the consent form. 
 
Assigning a Subject ID: After informed consent is obtained, the Research Coordinator will 
assign each participant a 6-digit Subject ID number. The first 2 digits identify the clinical 
site, e.g. “01” for UTSW, followed by the number unique to the participant, encountered 
consecutively; thus, patient #1 at UTSW would receive the Subject ID 010001. Patient #7 
at UAB may be 020007. 
 
Randomization: The Data Coordinating Center (DCC) of the primary site (UTSW) will 
generate stratified randomization lists. Patients will be stratified by site, hysterectomy 
status, and duration since menopause (<10 & ≥10 years). The randomization lists with 
randomization codes will be distributed to each site’s research pharmacy. After informed 
consent is obtained, the Research Coordinator will alert the research pharmacy, and the 
pharmacist will assign and record the participant’s unique Randomization Code. He/she 
then dispenses the appropriate study cream (active CE cream vs. placebo cream). Those 
conducting the primary and secondary measurements as well as the patients will be blinded 
to treatment assignment.  These data will not be housed in the study’s database (i.e., 
REDCap). For medical reasons, there will be a protocol for breaking this blinding for 
providers needing to understand the medication that the patient is receiving.  
5 
STUDY INTERVENTIONS  
5.1 Interventions, Administration, and Duration  
Drug administration and dosing schedule: CE cream application dose and frequency will 
follow typical recommendations and the protocols observed in other clinical trials of CE 
cream, i.e. 1g applied vaginally nightly for 2 weeks followed by twice-weekly application. 
The research pharmacy at each site will house and dispense study medication. At Baseline, 
Surgery, and 6-mo postoperatively (i.e., Tubes #1, #2, and #4, respectively), the study 
cream will be dispensed directly to the patient (via Research Coordinator). At 3- and 9-mo 
postoperatively (Tubes #3 and #5, respectively), the study cream will be sent by the 
Research Coordinator to the participant via FedEx (or similar) once dispensed by the 
pharmacist. 
 
Dose adjustments or escalation, changes in formulation: not applicable 
 
Potential adverse effects: 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
14 
Premarin® vaginal estrogen cream may cause some, all, or none of the side-effects listed 
below.  
Minor side effects: vaginal itching (2-3%), breast tenderness (2-3%), vaginal discharge 
(6-11%)*, joint aches (7-9%)*, headache (10-13%)*. 
Severe side effects: stroke (<1%), blood clots in the legs or lungs (<1%) 
 
* = in clinical studies, the rates of these side-effects were comparable in patients treated 
with estrogen and placebo vaginal creams. 
5.2 Handling of Study Interventions  
Pfizer, Inc has agreed to provide active CE cream (Premarin® vaginal cream, PVC) for the 
study. A separate, central pharmacy has been identified that is able to produce placebo 
cream and receive/procure the CE cream from Pfizer. Pfizer will provide identical tubes to 
the PVC for the placebo cream; all tubes will be over-labeled with an opaque label to mask 
active vs. placebo cream. This central pharmacy, Particle Sciences, Inc. (PSI), was 
established in 1991 as a Contract and Research Development company. It has extensive 
experience in pharmaceutical formulation development and characterization, especially in 
the area of nanoparticle suspensions and emulsions. It has substantial prior experience in 
production and stability testing of complex formulations—including hormone creams—
under good manufacturing practices (cGMPs).  
 
Placebo development: PSI guarantees development of placebo cream that is comparable in 
appearance, pH, and viscosity to the active study cream and test it for stability in batches 
at 0, 3, and 6 months, including under conditions designed to simulate 2-year stability, i.e. 
“accelerated stability” testing at 40oC and 75% relative humidity (in addition to standard 
testing at 25oC and 60% relative humidity). PSI is then able to provide the appropriate 
oversight and quality assessments of placebo cream manufacture once a satisfactory recipe 
is generated. 
 
Study drug distribution & storage: PSI will coordinate with research pharmacists at each 
clinical site to assure a reliable supply of study creams are shipped to the research 
pharmacies. It is anticipated that batches will be shipped approximately quarterly. CE 
cream and its placebo are stable for storage and shipment at room temperature. 
 
Unused cream: Study cream tubes will all be weighed before being dispensed, and study 
participants will be asked to return their used tubes to the Research Coordinator (upon 
receipt of their next tube) in order to weigh these spent tubes and calculate total 
volume/grams cream used. This will be one metric of participant adherence to study 
medication. Unused cream will be destroyed by the Research Coordinator or the research 
pharmacist of the Investigative Drug Services pharmacies. 
 
Accountability records: Study participants will be provided a “Medication Calendar” and 
given instructions for marking the days that they apply their study cream. Subjects will be 
asked to return their Medication Calendar along with the remaining study cream tube at 
their follow-up visits. Additional detail is provided in the Manual of Operations & 
Procedures. 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
15 
5.3 Concomitant Interventions 
5.3.1 Allowed Interventions 
• Medications: If vaginal discharge is encountered during the setting of study cream 
use, e.g. vaginal Candidiasis or bacterial vaginosis, appropriate treatment may be 
provided. For simplicity of not having to coordinate application of multiple vaginal 
creams (e.g., study cream and anti-fungal cream), oral treatments are preferred, e.g. 
diflucan or metronidazole pills for Candidiasis or bacterial vaginosis, respectively. 
• Surgical: in addition to the required surgical intervention of uterosacral or 
sacrospinous ligament suspension (see 5.3.2), anterior/ posterior colporrhaphies, 
vaginal hysterectomy, and midurethral slings are allowed. 
5.3.2 Required Interventions  
• Surgical: All patients will undergo uterosacral ligament suspension (“USLS”) 
similar to that described by Shull76 and a prior network (PFDN) surgical trial68 with 
agreement on number, placement, and type of sutures: 2-3 sutures placed bilaterally 
(4-6 total) beginning at or above the level of the ischial spine, with 1 delayed 
absorbable suture caudad and 1 or 2 permanent monofilament suture(s) ~1 cm 
cephalad. If uterosacral ligaments are deemed unusable due to scarring or 
inaccessibility—or by surgeon preference—the surgeon may instead perform a 
unilateral sacrospinous ligament fixation (“SSLF”) in the same fashion described 
previously68 also with 2 permanent and 2 delayed absorbable sutures (4 total). 
Based on level I evidence, neither USLS nor SSLF is superior to the other for 
anatomic, functional, or adverse event outcomes.69 Participating study surgeons 
must have performed ≥20 of each vault suspension procedure with ≥5 in the 12 
months before subject enrollment. 
5.3.3  Prohibited Interventions 
• Medications: Any oral or transdermal estrogen, Selective Estrogen Receptor 
Modulator (SERM), or other medication impacting vaginal milieu 
• Surgical: Any placement of transvaginal mesh for prolapse 
5.4 Adherence Assessment  
 
The planned analyses will be according to a modified intention-to-treat principle (mITT): 
i.e., all participants that are randomized and undergo a surgical prolapse repair and have at 
least one postoperative assessment will be analyzed according to their randomized 
assignment group. All eligible subjects who consent to the study and are enrolled will be 
available for analysis of baseline characteristics, and those that are randomized and use 
their study drug will be monitored for adverse events, but they must meet the additional 
qualifications above (i.e., undergo surgery and have a postoperative assessment) to be 
analyzed for the primary study outcome. 
 
Various per-protocol analyses will also be considered, the first being an analysis similar to 
the modified ITT above but for only those participants receiving the per-protocol surgical 
repair (USLS or SSLF, see 5.3.2). Other per-protocol analyses will be comparisons of the 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
16 
subset of participants in the two randomized groups who are adherent to their study 
medications. Therefore, defining drug adherent is critical. This will be defined in three 
ways: “strict”, “per pivotal study”, and objectively using VMI. 
 
“Strict” Adherence Definition 
Drug adherent will be defined as >80% compliant to expected dosing using the 
subject’s returned tubes (i.e., comparing returned tube weights to that expected with at 
least 80% adherence) and/or Medication Calendar. Should there be a discrepancy in 
adherence designation between tube weight and medication calendar (e.g., using tube 
weights, the participant appears to have been non-adherent to study protocol but her 
calendar suggests she was adherent with at least 80% of planned doses recorded as 
completed), we will defer to the more objective tube weight. 
 
“Per Pivotal Study” Adherence Definition 
One of the 3 recommended dosage and administration schedules per Pfizer’s package insert 
for Premarin® cream is twice-weekly administration of 0.5g intravaginally. This was based 
on a pivotal study by Bachmann et al in 2009.63 In this study, the twice-weekly CE group 
of participants was defined as adherent with their drug if they self-reported, on average, at 
least once-weekly (and not more than three times weekly) application of the cream on their 
paper diary; medication tube weights were not collected. Similarly, in IMPROVE, if 
participants report via their Medication Calendar that they have applied their cream at least 
50% of what is expected, this will be considered adherent. 
 
Alternative Definition: using VMI 
Cytomorphologically, vaginal atrophy can be defined by high numbers of (para)basal and 
intermediate cells and very low numbers of superficial cells. In a prolonged low-estrogen 
state, superficial cells are no longer produced, leaving essentially only parabasal and basal 
cells lining the vaginal wall. The Vaginal Maturation Index (VMI) will serve as an 
important objective tool to assess patient adherence with local estrogen application in those 
participants randomized to vaginal estrogen. This is a quantifiable measure of the 
proportion of vaginal epithelial superficial cells to parabasal and intermediate cells. While 
there is not a universally agreed-upon formula to calculate VMI or a cutoff to absolutely 
define “atrophic” vs. “estrogenized”, several studies point toward the following77: 
 
 0 x % parabasal cells + 0.5 x % intermediate cells + 1.0 x % superficial cells. 
  
A cutoff of 50 or less is indicative of atrophy.78 Therefore, a score >50 is indicative of 
study drug adherence in those randomized to active CE cream. 
 
The ThinPrep® system and its alcohol-based fixative allows for immediate cell fixation 
after swabbing of the upper vagina with a plastic spatula so the specimen is stable for 
transport to UT Southwestern for analysis, and the automated system assures greater 
uniformity and consistency in slide preparation. The VMI assessment will be conducted by 
a blinded examiner (Dr. Thibodeaux and/or his trained designee). 
 
The VMI will be collected at Baseline, at time of surgery (or Pre-op clinic visit), and at 12 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
17 
months postoperatively; if the participant is withdrawing or withdrawn before 12 months 
postoperatively, a final visit VMI will be collected. While this will provide objective 
assessment of adherence in those patients randomized to active CE cream, it will not suffice 
for those randomized to placebo cream (in which case, even adherent patients are expected 
to demonstrate objective atrophy on VMI) or when participants are unwilling to have VMI 
collected or if the specimen is deemed uninterpretable by the blinded pathologist.  
6 
STUDY PROCEDURES 
See next page for Schedule of Evaluations (6.1) 
 
PFD (Pelvic Floor Disorder) Questionnaires consist of 3 validated short-form (in English 
and Spanish) PFD questionnaires (already used as standard of care at patient intake): Pelvic 
Floor Distress Inventory (PFDI-2073), Pelvic Floor Impact Questionnaire (PFIQ-773), 
Pelvic Organ Prolapse/ Urinary Incontinence Sexual Function Questionnaire (PISQ-IR74) 
plus a 6-question survey of vaginal atrophy symptomatology75, a general quality-of-life 
(QoL) instrument (SF-12), and a body image questionnaire. 
 
 
 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
18 
Schedule of Evaluations
 
(Table 1)Assessment 
Baseline (≥5wk 
before 
Surgery) 
Preop 
Visit (w/in 
2wk of 
surgery) 
Surgery/ 
Hospitalization 
1mo 
Postop 
Visit  
(±2wk)** 
3mo 
Postop 
Call 
(±2wk) 
6mo 
Postop 
Visit 
(5-7mo) 
9mo 
Postop 
Call 
(±2wk) 
12mo 
Postop 
Visit 
(10-14mo) 
18&30mo 
Postop 
Calls 
(±2wk) 
24&36mo 
Postop 
Visits 
(±2mo) 
Informed Consent Form, 
Inclusion/Exclusion, 
Randomization  
X 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
Exam: POP-Q 
X 
 
 
X 
 
X 
 
X 
 
X 
Exam: Levator muscle 
strength assessment 
X 
X 
 
X 
 
X 
 
X 
 
X 
Exam: Vaginal  atrophy 
assessment 
X 
X 
X 
X 
 
X 
 
X 
 
X 
Exam: vaginal epithelium/ 
granulation tissue 
assessment 
X 
X 
 
X 
 
X 
 
X 
 
X 
Medication Review 
X 
X 
 
X 
X 
X 
X 
X 
X 
X 
PFD Questionnaires 
X 
X 
 
 
X* 
X 
X* 
X 
X* 
X 
PGI-I and/or PGI-S 
X 
 
 
 
 
X 
 
X 
 
X 
Vaginal Maturation Index 
X 
 
X 
 
 
 
 
X 
 
 
Blood Serum (E1, E2)  
X 
 
 
 
 
 
 
X 
 
 
Blood (whole), storage for 
DNA/ genetics assessment 
(optional) 
X 
 
 
 
 
 
 
 
 
 
Vaginal Wall Biopsy 
(optional) 
 
 
X 
 
 
 
 
 
 
 
Study CreamTube No. 
delivery/receipt 
X1 
 
X2 
 
X3 
X4 
X5 
 
 
 
Medication CalendarTube No. 
collection 
 
X1 
 
 
X2 
X3 
X4 
X5 
 
 
Preop History/Exam 
 
X 
 
 
 
 
 
 
 
 
Postop Med/Surg update 
 
 
 
X 
X* 
X 
X* 
X 
X* 
X 
Postop Extra Treatment 
 
 
 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
19 
Adverse Event, Protocol 
Deviation forms 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 
PRN 
POP-Q, pelvic organ prolapse quantification examination; PFD, Pelvic Floor Disorder; PGI-I and –S, Patient Global Impression of 
Improvement, - Severity; E1, estrone; E2, estradiol 
 
*,  At these times (3, 9, 18 and 30-mo postoperatively), these are phone call “visits” only with no questionnaires or exam. However, the 
coordinator will phone the participant to query and document: (a) if she has symptoms of a bulge or, “something falling out that you can 
see or feel in your vaginal area”, which is Question #3 of the PFDI-20; (b) she has had treatment for pelvic organ prolapse since the last 
visit date; (c) she is experiencing new medical problems or complications; (d) she has been hospitalized, had surgery, been to the 
emergency department, or visited a doctor for urologic or gynecologic conditions since the last visit date; and (e) she has had any change 
in her medications. A reminder of the next in-person study visit is also given. 
 
 
**, Clarification of timing of postoperative visits: the 1-month postop visit is defined as one calendar month after surgery. For example, 
if surgery is on July 1, one month postop is Aug 1, then ±2 week. This is to differentiate from surgery date + 4 weeks or surgery date + 
30 days. Likewise, the 6-month postop visit is January 1, ±1 month; and the 12-month postop is July 1 of the following year, ±2 months.  

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
20 
6.2 Description of Evaluations  
6.2.1 Consent/Screening Evaluation 
Consenting Procedure 
At the same patient encounter, both the consenting process and patient screening will 
occur. Generally, this will be the patient’s initial encounter in the Urogynecology clinic 
but it may at any visit at which the patient selects surgical repair of symptomatic pelvic 
organ prolapse; for example, perhaps she previously had been managed with 
conservative measures such as pessary placement. The informed consent and the 
history and exam findings will be collected in a private room. The informed consent 
document will be written and provided in English or Spanish. Translator services are 
available at all study sites. Either the research coordinator or another member of the 
research team (PI or co-investigator) will be obtaining the consent, and the patient will 
sign and date/time her name to indicate understanding, which will be observed and 
countersigned by a witness.   
 
Annual review of the consent document will be done in conjunction with continuing 
review by each clinical site’s Institutional Review Board (IRB), and updates will be 
made as deemed appropriate. If other modifications to the document are deemed 
necessary by the research team (e.g., a change in protocol or known risk of study 
intervention), these modifications will be communicated to the IRB for approval. 
 
Screening   
Screening for eligibility will be relatively simple. Most inclusion/exclusion criteria are 
readily assessed from the patient’s routine intake history and physical examination 
completed as part of usual care upon presentation to a Urogynecology clinic. For 
example, this history/exam would have already identified a symptomatic 
postmenopausal patient with prolapse not using any form of estrogen supplementation 
and an exam consistent with the eligibility criteria: stage 2 or greater anterior and/or 
apical prolapse and BMI ≤35 kg/m2. No unique laboratory, radiology, or other invasive 
examination or testing is required to determine study eligibility beyond the history and 
examination performed as part of routine care in a Urogynecology clinic. 
 
There is no set maximum allowable time between which study eligibility may be 
determined and beginning study participation. The visit at which randomization occurs 
and study drug is dispensed (Tube #1) is deemed the Baseline visit, and eligibility 
should be re-confirmed at this time. 
6.2.2 Enrollment, Baseline, and/or Randomization 
Enrollment 
In this study, a single informed consent will encompass both screening and study 
procedures (as screening procedures are a part of routine care). Enrollment and 
randomization will occur on the same day all screening criteria are met and the 
individual agrees to participate. This enrollment/randomization date will be captured 
on a case report form at the Baseline assessment. 
 

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21 
Baseline Assessments 
• Contact Information (Form 01): name, address, phone, email data from patient 
and an alternative contact. Confirm patient’s assent to being contacted by text 
and/or email. 
• Demographics (Form 02): racial/ethnicity data and type of health insurance 
payer 
• Medical History (Form 03): smoking history, confirmation of postmenopausal 
status, hysterectomy status, and assessment for history of recurrent urinary tract 
infection, diabetes, connective tissue disease, and various medical conditions 
• Baseline Physical Exam (Form 04): gather height, weight, Pelvic Organ 
Prolapse Quantification (POP-Q) exam,  uterine size, levator muscle tone and 
strength, investigator assessment of vaginal atrophy, and vaginal maturation 
index (VMI) specimen collection (see below). 
• Medication Review (Form 05): list all medications related to treatment of 
incontinence and overactive bladder 
• Pelvic Floor Disorder (PFD) Questionnaires (Form 10): see description above 
in 6.1 
• Patient Global Impression of Severity (PGI-S) (Form 11): 1-question tool 
validated for urinary incontinence and modified for POP. Assesses overall 
impression of symptom severity related to POP. 
• Vaginal Maturation Index (VMI): See also Section 5.4. A standard plastic 
spatula (similar to those used for a Pap smear and readily available in any 
gynecology clinic) will be used to sample the upper vaginal walls for 15-30 
seconds. The spatula will be swirled in a ThinPrep container (labeled with a 
preprinted barcode label with a Specimen ID linked with the participant's 
Subject ID number), which is then stable when stored at room temperature or 
4oC and shipped with cold packs in a cold shipping box for storage at UTSW. 
• Blood serum collection: Blood will be drawn into a standard red top tube. 5mL 
(1 teaspoon) is gathered to assess baseline estrone (E1) and estradiol (E2) levels.  
o Tube: Red top glass, no additive, no clot activator with uncoated 
interior, vacutainer tubes (BD366430 - 16 x 100 mm x 10.0 ml) 
o Do not draw from an IV or shunt. 
o Post-collection: allow to clot for 20-50min (room temperature) 
o Centrifuge (after balancing) at 1000-2000 g (RCF) for 15 minutes. 
Although most clinical blood centrifuges only spin at one speed, one 
will need to compute the rpm’s of the specific centrifuge to give 1000-
2000 g.  The method to convert RCF in g’s to rpms is based on the 
centrifuge’s radius of rotation. 
o Using a transfer pipette, the serum is removed from the red top tube 
(being careful not to disturb the clot) and dispensed into a screw-on top 
plastic tube for transport. 
o The transport tube is capped securely. A preprinted barcode label with 
the Specimen ID is affixed.  
o The stopper is replaced in the original red top tube, which is discarded 
with the transfer pipette in a biohazard container. 
o Serum may either be shipped within 24 hr of collection on cold packs in 

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22 
a cold shipping box or stored at -20oC and shipped on dry ice to UTSW 
(e.g., if bundling with other samples for efficiency). 
• Whole blood collection (optional): Blood will be drawn into a standard yellow 
top tube. 5mL (1 teaspoon) is gathered at baseline. After appropriate processing 
and shipment, these specimens will be aliquoted and stored at UT Southwestern 
for possible future aims to include DNA analysis and studies examining for 
genetic predictors of surgical success/failure.  
 
Randomization (Form 06) 
Randomization to either active CE cream or placebo cream will be assigned by the 
research pharmacist using the allocation tables provided to him/her previously by the 
DCC. Stratification will be by site, hysterectomy status, and years since menopause 
(<10 and ≥10). The pharmacist is alerted to the subject once she has completed the 
consent process and has been assigned a Subject ID number. The 4-digit 
Randomization Number will be given by the pharmacist to the Research Coordinator. 
At this time, study drug may either be dispensed directly to the patient (via the Research 
Coordinator) or, if timing is preferable, may be shipped to the patient via FedEx. The 
patient is to begin study cream application immediately (that evening) once obtaining 
the cream and document use on the Medication Calendar. 
• Dispensation of study drug (Tube #1) is documented (Form 07) 
• Protocol Deviation (Form 21): as needed 
 
6.2.3 Follow-up Visits 
Preoperative Visit (within 2wk of Surgery): 
• Medication Review (Form 05): updated from Baseline 
• Medication Calendar documentation (Form 07) of study drug use Baseline-to-
Pre-op 
• Pelvic Floor Disorder (PFD) Questionnaires (Form 10) 
• Preop Visit and Physical Exam (Form 12): assesses for any possible complaints 
or complications related to study cream application and re-assesses levator 
muscle tone and strength, and investigator assessment of vaginal 
atrophyVaginal Maturation Index (VMI) for “Surgery” time point may be 
collected at this visit if it falls within 7 days of surgery. 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
Surgery/Hospitalization: 
• Surgeon’s Report (Form 13): confirmation of VMI collection, investigator 
assessment of atrophy, surgeon assessment of tissue quality, confirmation of 
prolapse repair per protocol or reasons for deviation from protocol (if any), 
intraoperative complications. 
• Hospitalization (Form 14): days hospitalized, bladder voiding status at 
discharge, immediate postoperative complications 
• Return of study drug (Tube #1) and dispensation of Tube #2 is documented 
(Form 07). Tube #2 is dispensed to the subject with instructions to resume 
twice-weekly use once discharged home. The weight of Tube #1 is documented 

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23 
and the tube appropriately disposed/destroyed. 
• Medication Calendar (Form 07) documenting use of Tube #1 (Baseline-to-
Surgery) is collected (if not already completed at Pre-op).  
• Vaginal wall biopsy: an optional small full-thickness biopsy (triangle 
approximately 1.5x1 cm) will be obtained from the apical/ cephalad anterior 
vaginal wall (shown in figure below from an abdominal perspective). This is 
tissue that ordinarily would be discarded in the course of an anterior vaginal 
wall repair (colporrhaphy) procedure. This will be placed in buffered solution 
(RNAlater®). A preprinted barcode label with a Specimen ID is affixed. This 
is stable when stored at 4oC. It is shipped to UTSW on cold packs for later 
histologic assessment and qPCR for mRNA testing. Tissue collected locally at 
UTSW will initially be delivered for processing to the lab in phoshate-buffered 
saline (PBS), allowing additional analysis by zymography (protease enzyme 
activity), immunoblotting, and hydroxyproline assay for cross-linked collagen 
content. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 4. Vaginal wall biopsy (For 
orientation, a suture is placed loosely 
on the mid-portion of the apical margin 
of the triangular specimen) 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
1-month Postoperative Visit (2-6wk Postop): 
• Medication Review (Form 05): updated from Preop Visit 
• Surgical pathology review is confirmed (Form 14b) and, if abnormal, prompts 
completion of adverse event documentation (Form 09) 
• Postop Medical/Surgical History update (Form 15): documents any interval 
treatments for prolapse or urinary symptoms, interval medical history. 
• Postop Exam (Form 16): re-assesses levator muscle tone and strength, 
investigator assessment of vaginal atrophy, examination for vaginal suture or 
mesh exposure/ ulcerations/ granulation tissue, and repeat POP-Q examination 
• Postop Extra Treatments (Form 17): as needed 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
3-month Postoperative Phone Call (±2wk): 

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24 
• Postop phone call documentation (Form 18) completed, with follow-up 
questions about feelings of vaginal pressure/ bulging and if there has been 
treatment for prolapse since the last study visit. 
• Study cream Tube #3 is dispensed to the subject via FedEx with instructions to 
continue twice-weekly application.  
• Medication Calendar (Form 07) documenting use of Tube #2 (Surgery-to-3mo) 
is collected either by mail or fax (or reminder to bring calendar to 6mo Postop 
Visit). Reminder to bring Study cream Tubes #2 and #3 to next appointment. 
• Medication Review (Form 05): updated from 1-month Postop Visit 
• Postop Extra Treatments (Form 17): as needed 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
6-month Postoperative Visit (±1mo): 
• Study cream Tube #3 is collected (and #2, if not previously collected). Study 
cream Tube #4 is dispensed to the subject with instructions to continue twice-
weekly application (Form 07). The weight of Tubes #2 and #3 are documented 
and the tubes appropriately disposed/destroyed. 
• Medication Calendar documenting use of Tube #3 (3mo-to-6mo) is collected 
(Form 07).  
• Medication Review (Form 05): updated from 3-month Postop Call 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
• Pelvic Floor Disorder (PFD) Questionnaires (Form 10) 
• Patient Global Impression of Severity (PGI-S) and Patient Global Impression 
of Improvement (PGI-I) (Form 11): 1-question tools assessing overall 
impression of symptom severity and improvement related to POP. 
• Postop Medical/Surgical History update (Form 15) 
• Postop Exam (Form 16) 
• Postop Extra Treatments (Form 17): as needed 
 
9-month Postoperative Phone Call (±2wk): 
• Postop phone call documentation (Form 18) completed, with follow-up 
questions about feelings of vaginal pressure/ bulging and if there has been 
treatment for prolapse since the last study visit. 
• Study cream Tube #5 is dispensed to the subject via FedEx with instructions to 
continue twice-weekly application.  
• Medication Calendar (Form 07) documenting use of Tube #4 (6mo-to-9mo) is 
collected either by mail or fax (or reminder to bring calendar to 12mo Postop 
Visit). Reminder to bring Study cream Tubes #4 and #5 to next appointment. 
• Medication Review (Form 05): updated from 6-month Postop Visit 
• Postop Extra Treatments (Form 17): as needed 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
12-month Postoperative Visit (±2mo): 
• Study cream Tube #5 is collected (and #4, if not previously collected) (Form 
07). The weight of Tubes #4 and #5 are documented and the tubes 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
25 
appropriately disposed/destroyed. 
• Medication Calendar documenting use of Tube #5 (9mo-to-12mo) is collected 
(Form 07).  
• Medication Review (Form 05): updated from 9-month Postop Call 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
• Pelvic Floor Disorder (PFD) Questionnaires (Form 10) 
• Patient Global Impression of Severity (PGI-S) and Patient Global Impression 
of Improvement (PGI-I) (Form 11) 
• Postop Medical/Surgical History update (Form 15) 
• Postop Exam (Form 16) 
• Postop Extra Treatments (Form 17): as needed 
• Specimen collection, preparation, and shipment to UTSW: blood/serum (sent 
on cold packs within 24 hr of collection or store at -20oC and ship on dry ice) 
and VMI  (store at 4oC and ship on cold packs) 
 
18-month Postoperative Phone Call (±2wk): 
• Postop phone call documentation (Form 18) completed, with follow-up 
questions about feelings of vaginal pressure/ bulging and if there has been 
treatment for prolapse since the last study visit. 
• Medication Review (Form 05): updated from 12-month Postop Visit 
• Postop Extra Treatments (Form 17): as needed 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
24-month Postoperative Visit (±2mo): 
• Medication Review (Form 05): updated from prior call or visit 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
• Pelvic Floor Disorder (PFD) Questionnaires (Form 10) 
• Patient Global Impression of Severity (PGI-S) and Patient Global Impression 
of Improvement (PGI-I) (Form 11) 
• Postop Medical/Surgical History update (Form 15) 
• Postop Exam (Form 16) 
• Postop Extra Treatments (Form 17): as needed 
 
30-month Postoperative Phone Call (±2wk): 
• Postop phone call documentation (Form 18) completed, with follow-up 
questions about feelings of vaginal pressure/ bulging and if there has been 
treatment for prolapse since the last study visit. 
• Medication Review (Form 05): updated from 12-month Postop Visit 
• Postop Extra Treatments (Form 17): as needed 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
 
36-month (Final) Postoperative Visit (±2mo): 
• Medication Review (Form 05): updated from prior call or visit 
• Adverse Events (Form 09) and Protocol Deviation (Form 21): as needed 
• Pelvic Floor Disorder (PFD) Questionnaires (Form 10) 

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26 
• Patient Global Impression of Severity (PGI-S) and Patient Global Impression 
of Improvement (PGI-I) (Form 11) 
• Postop Medical/Surgical History update (Form 15) 
• Postop Exam (Form 16) 
• Postop Extra Treatments (Form 17): as needed 
 
 
6.2.4 Completion/Final Evaluation 
See 36-month Postoperative Visit above. 
 
At the completion of 36 months or at the participant’s final visit (if early withdrawal), 
“Final Status” documentation (Form 20) will be completed. This gives the following 
possible reasons for withdrawal: ineligible/ screen failure (few, if any, of these are 
anticipated); subject never began Study Cream; subject did not complete/undergo 
surgery; subject voluntarily withdrew from study (reason specified); investigator 
withdrew patient from study (reason specified); lost to follow-up; death; transition to 
long-term resident or skilled nursing facility; study termination; other (reason 
specified). 
 
Possible reasons for early withdrawal by the subject may include intolerance of the 
study medication, patient preference, or inability to continue with follow-up 
examinations and assessments. Early withdrawal of the participant by the investigator 
may also be for participant’s inability to adhere to study medication or visits. 
 
If a participant withdraws (or is withdrawn) after randomization but before 12 months 
postoperatively, there is a prompt to the research coordinator/ physician examiner to 
collect a final VMI specimen. 
 
It is not anticipated that participants will need to continue to be monitored after study 
withdrawal and discontinuation of the study medication. 
7 
SAFETY ASSESSMENTS  
All participants will be monitored for safety and the emergence of adverse events. As 
detailed in Section 6.2.3, adverse events (Form 09) are queried and inventoried at all 
follow-up appointments. Of note, the surgery is not the study intervention—although 
adverse events encountered with surgery will be documented and followed. With respect 
to the actual study intervention, i.e., application of vaginal estrogen cream, these are the 
expected adverse experiences/toxicities documented in prior studies:  
 
Minor side effects: vaginal itching (2-3%), breast tenderness (2-3%), vaginal discharge 
(6-11%)*, joint aches (7-9%)*, headache (10-13%)*. 
Severe side effects: stroke (<1%), blood clots in the legs or lungs (<1%) 
 
* = in clinical studies, the rates of these side-effects were comparable in patients 
treated with estrogen and placebo vaginal creams 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
27 
 
If minor side effects such as those listed above are encountered early in the study (e.g., in 
the preoperative time period between baseline and surgery), the participant will be 
encouraged to try to continue the study medication with reassurance and as-needed 
therapies such as acetaminophen for management of headache or body aches or breast 
tenderness. Vaginal discharge—if related to Candidiasis or bacterial vaginosis—can be 
treated with oral medication as detailed in 5.3.1. Frequently, these minor side effects are 
found to be transient. If at any time these effects are more bothersome to the patient and 
persist despite attempts at management, the study medication will be discontinued, but the 
patient will continue to be monitored if she has not withdrawn from the study.  
 
If severe side effects such as those listed above are encountered and thought possibly due 
to study medication, the study medication will be discontinued. 
7.1 Specification of Safety Parameters 
No particular safety measures or laboratory parameters are pre-specified to direct the 
investigators to discontinue the study medication in a participant. 
7.2 Methods and Timing for Assessing, Recording, and Analyzing Safety Parameters 
As detailed in Item 6.2.3, possible safety issues or adverse events (Form 09) are queried 
and inventoried at all follow-up appointments. 
 
The actual risks of the intervention in this study, conjugated estrogen (CE) cream (i.e., 
Premarin cream), at the planned dose and frequency, are minor. In a well-done, large study 
comparing CE cream to placebo cream (Bachmann 2009, total n=423)63 with 12mo follow-
up, these adverse events were reported; there were no statistically significant differences 
between CE cream and placebo cream: 
• vaginal discharge or leukorrhea: CE cream 6.1%, placebo 10.5% 
• headache: CE cream 11.5%, placebo 12.8% 
• arthralgia: CE cream 7.7%, placebo 8.3% 
• any adverse event leading to drug discontinuation (12 wk): CE cream 3.5%, placebo 
2.1% 
 
In a different study comparing vaginal CE cream (also 0.625mg/1 g) to an oral synthetic 
estrogen (Botsis 1997, total n=72, 6mo follow-up)79, these adverse events were reported; 
as above, they were not statistically different between treatment arms: 
• vaginal itching: CE cream 2.8%, Synthetic PO estrogen: 2.8% 
• breast tenderness: CE cream 2.8%, Synthetic PO estrogen: 2.8% 
 
Finally, in another larger study comparing CE cream to placebo cream (Freedman 2009, 
total n=305, 12-wk follow-up)80, ANY adverse event was reported in 55% of patients using 
CE cream and 47% using placebo cream, but AE's bothersome enough for withdrawal from 
the study occurred in just 3 of 150 (2%) CE cream patients and 2 of 155 (1.3%) placebo 
cream patients. 

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28 
 
Risk of a severe side effect related to this dosing of CE cream (i.e., stroke, deep vein 
thrombosis, or pulmonary embolism) is less than 1%.  
 
Although systemic absorption of vaginal estrogen has been documented, in this trial we 
will use low dosage vaginal CE cream (1g of 0.625mg/g cream) because this therapy does 
not involve significant increases in estrogen in blood and has been shown to have positive 
effects on postmenopausal vaginal atrophy. Women at high risk for potential adverse 
effects from systemic absorption of estrogen (specifically stroke, blood clots in the lungs 
or deep veins of the legs, or breast, ovarian or endometrial cancer) are excluded from study 
participation. 
 
Any hypothetical adverse event involving endometrial pathology related to estrogen 
exposure (i.e., hyperplasia, cancer) is not applicable in this study as all participants will 
either be status-post hysterectomy or undergoing total vaginal hysterectomy at the time of 
the planned prolapse repair surgery. 
7.3 Adverse Events and Serious Adverse Events  
Definitions: 
• An adverse event (AE) is defined as any unfavorable and unintended diagnosis, 
symptom, sign (including an abnormal laboratory finding), syndrome or disease 
which either occurs during the study, having been absent at baseline, or if present 
at baseline, appears to worsen. Adverse events will be recorded regardless of their 
relationship to the study intervention (Form 09). 
 
• A serious adverse event (SAE) is defined as any untoward medical occurrence 
that results in death, is life threatening, requires inpatient hospitalization or 
prolongation of existing hospitalization, results in persistent or significant 
disability/incapacity, or is a congenital anomaly (Form 09b). 
 
No pre-specified laboratory measures will be collected to assess safety. 
 
These AE’s will be collected as solicited events (Forms 09, 12, 13, 14, 15): 
• Vaginal or vulvar complaints possibly associated with vaginal estrogen cream: 
itching, irritation, vaginal or vulvar rash, yeast infection or other discharge. 
• Non-vaginal complaints anticipated with the use of vaginal estrogen cream: breast 
tenderness, join aches, headache. 
• Intraoperative AE’s: bladder perforation, ureteral injury, urethral injury, rectal 
injury, other bowel injury, major vascular injury, anesthesia-related complications. 
• AE’s encountered during hospitalization after surgery: blood transfusion, wound 
complications, febrile or dermatologic complications, organ damage complications, 
cardiovascular 
complications, 
pulmonary 
complications, 
gastrointestinal 
complications, neurological complications, other. 
• AE’s encountered or reported at postoperative visits: vaginal or vulvar complaints 
(as above)/ non-vaginal complaints (as above) possibly related to estrogen 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
29 
application, wound complications, febrile or dermatologic complications, 
neurological complications, other. 
 
Case report forms (Forms 09, 13, 14, 15) all offer lines for data entry for “other” events, 
and Form 09 gives a reminder as to events triggering a SAE designation (Form 09b). 
 
Possible safety issues or adverse events are queried and inventoried at all follow-up 
appointments and calls. 
7.4 Reporting Procedures 
Each clinical investigator is responsible for reporting serious or unexpected adverse events 
to the IRB at their institution and to the Safety Monitor. The Safety Monitor/Officer 
(currently DSMB Chair, Dr. Thomas Gregory), DCC Biostatistician (currently Dr. Linda 
Hynan), and NIA Project Scientist or Program Officer are notified by email when a report 
of any serious adverse event is entered into the REDCap database. The Safety Monitor 
summarizes the case; if it is potentially related to the intervention, the Safety Monitor 
reports it to the NIA Program Officer and the remaining DSMB members in an expedited 
manner (i.e., within 24 hours of learning of these events). The Safety Monitor (currently 
Dr. Thomas Gregory) will determine whether the case should be reported to the IRBs at all 
the institutions participating in the trial. The DCC summarizes all SAE’s, including those 
that are definitely not related to the intervention, for the DSMB at each DSMB meeting. 
 
Approximately every 6 months, or more frequently upon request of the Chair of the DSMB, 
the DCC will summarize all adverse events (including serious, unexpected and expected) 
by randomization group in a report to the DSMB. In addition, the report will contain accrual 
and drop-out rates. The DSMB will summarize their findings to the NIA with approval to 
continue the clinical trial, or a recommendation to modify the trial or terminate the trial. 
 
Further, in accord with Investigator-Initiated Research (IIR) clinical studies with Pfizer, all 
serious adverse events will also be submitted to Pfizer via their IIR SAE form; this applies 
to all subjects receiving a Pfizer product (i.e. Premarin cream) or blinded therapy and also 
includes those SAEs not study-drug-related. The clinical study reporting period begins 
from the time that the subject receives her first dose of Pfizer product (or blinded therapy) 
through and including 28 days after the last administration of the Pfizer product (or blinded 
therapy). The time frame for reporting the SAE to Pfizer is immediately upon awareness 
(if fatal or life-threatening SAE) or within 24 hours of first awareness (if not fatal or life-
threatening). The PI will include a rationale and medical justification as an assessment of 
causality, i.e., the determination of whether there is a reasonable possibility that the Pfizer 
product (or blinded therapy) caused or contributed to an AE. Finally, new, updated, or 
corrected information about a previously-reported SAE will also be communicated to 
Pfizer in a follow-up report. 
7.5 Follow-up for Adverse Events 
The PI and biostatistician at UTSW will be responsible for: 
• maintaining an appropriate log of data regarding these events 
• monitoring the course of the event to resolution or the end of the trial 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
30 
• notifying all site investigators of all serious adverse events for appropriate 
reporting to their local Institutional Review Boards 
• reviewing updated blinded, aggregate data summarizing participant safety. These 
reports will include incidence, severity, and relatedness to treatment of all reported 
and treatment emergent Adverse Events and withdrawals from the trial due to 
Adverse Events. 
7.6 Safety Monitoring 
The NIA has appointed a Data Safety Monoitring Board (DSMB), which will regularly 
evaluate the safety of the participants in IMPROVE. The IMPROVE UTSW PI and 
Biostatistician will be blinded to treatment allocation using dummy treatment group 
assignments while the DSMB and statistician/ programmer will be unblinded. The DSMB 
will consist of a chairperson and 2 other individuals who have expertise in clinical study 
design/ conduct and biostatistics. All board members will be independent of the institutions 
and investigators participating in the trial and have no financial ties to Pfizer (maker of 
Premarin® vaginal cream) or to the outcome of the trial. 
 
The DSMB will review the study design and plans for recruitment, adherence, 
interventions, data quality and safety monitoring. The responsibilities of the DSMB are to:  
• evaluate the safety of trial participants  
• ensure confidentiality of data and the results of monitoring 
• report to the UTSW PI and biostatistician on the safety of participants 
• make recommendations on continuation, termination, or  modifications to the trial 
 
DSMB Process: There will be 2 sections of the DSMB meeting: open and closed. In the 
open section of the meeting, the PI and Biostatistician will present the report to the DSMB 
and answer questions. The closed section of the meeting will include the members of the 
DSMB only. 
 
Reports to the DSMB, DSMB Review and Recommendations: The format of the report 
will be developed by the UTSW PI and biostatistician and approved by the DSMB. 
Additions and other modifications to the report may be directed by the DSMB. Interim 
DSMB reports generally consist of baseline characteristics, adverse events, serious adverse 
events and listings of extended evaluations by urogynecologists, if indicated, presented by 
dummy treatment group assignment. Adverse events will be categorized by seriousness 
and investigator-determined relationship to study drug. Data files to be used for interim 
analyses will have undergone established editing procedures to the extent possible, but all 
data, both edited and unedited, will be used to prepare interim reports. An unblinded 
statistician/ programmer will provide the dummy treatment group assignments to the 
IMPROVE biostatistician. In addition, the unblinded statistician/ programmer will prepare 
a confidential, sealed envelope to be included with the DSMB report using the real 
treatment assignment and an administrative assistant not associated with IMPROVE will 
mail the report one week in advance of the DSMB meeting. No other personnel at UTSW 
will have access to the real treatment assignment codes. The reports to the DSMB will be 
numbered and provided in sealed envelopes within an express mailing package to maintain 
confidentiality. All DSMB reports are confidential. A copy of the report will be retained in 

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31 
a locked, confidential file at the Coordinating Center. After each review, the DSMB will 
send a brief letter to the UTSW PI and biostatistician that contains a recommendation to 
continue, terminate, or alter the study.  
 
Access to Interim Data: Access to the accumulating safety and outcome data will be 
limited to as small a group as possible. 
 
Confidentiality: All materials and proceedings of the DSMB are completely confidential. 
8 
INTERVENTION DISCONTINUATION  
Condition for which the study intervention (CE cream) will be discontinued: 
• Intolerance of the study cream by the participant related to developing toxicity (e.g., 
allergy to conjugated estrogen or the vehicle in the active or placebo creams). This 
is determined by patient report and/or signs on physical examination, e.g. 
vulvovaginal skin irritation or inflammation: erythema, ulcerations, lesions, heat, 
tenderness, edema. 
 
Temporary study medication discontinuation: 
If symptoms or signs of vulvovaginal irritation exist but it is unclear whether this is related 
to study medication (e.g., vaginal discharge perhaps due to other conditions such as 
Candidiasis or bacterial vaginosis), these conditions may be treated with vaginal therapies 
(e.g. clotimazole or metronidazole or clindamycin creams) at the discretion of the clinical 
provider. In these scenarios, temporary discontinuation of the study medication cream may 
be deemed appropriate. The study cream should be resumed as soon as reasonably 
appropriate clinically. 
 
Elective study medication discontinuation by the participant:  
Subjects may, of course, withdraw voluntarily from participation in the study at any time 
and for any reason. Participants will continue to be followed, with their permission, even 
if the study intervention is discontinued. There are no planned modifications to the 
schedule and duration of continued follow-up after study medication discontinuation. 
 
There currently are not plans for replacement of subjects who discontinue early. 
 
If voluntary withdrawal occurs, the subject will be asked to continue scheduled evaluations, 
complete an end-of-study evaluation, permit collection of a VMI specimen, and be given 
appropriate care under medical supervision until the symptoms of any AE resolve or the 
subject’s condition becomes stable. 
9 
STATISTICAL CONSIDERATIONS  
9.1 General Design Issues  
A large simple trial (randomized, controlled) design was selected to evaluate for possible 
superiority of vaginal estrogen cream use compared to placebo. The primary outcome is a 
comparison by treatment group of time-to-failure of the prolapse repair at 1 year after 
surgery with “failure” defined by the any of these outcomes occurring: 

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32 
• Recurrent prolapse beyond the hymen of the anterior or posterior vaginal wall or 
apical descent >1/3 into the vaginal canal based on continuous measurements of the 
Pelvic Organ Prolapse Quantification (POP-Q)71 examination 
• Report of any symptoms of bulge: “yes” to question #3 of the Pelvic Floor Distress 
Inventory, “Do you usually feel a bulge or something falling out that you can see 
or feel in your vaginal area?” or no change or worse on the Patient Global 
Impression of Improvement (PGI-I). 
• Retreatment of prolapse with either pessary or surgery 
 
The null hypothesis for this study is that 12 months following transvaginal native tissue 
repair for prolapse with or without preoperative and continued postoperative local estrogen 
treatment, women will have the same rate of recurrent prolapse. The current definition of 
success in a surgical trial used by NICHD’s Pelvic Floor Disorders Network (PFDN) is 
this same composite of no prolapse beyond the hymen, no symptomatic recurrence, and no 
retreatment.81,82 
9.2 Sample Size and Randomization 
The literature reports failure by the above definition occurring in ~40% of patients with a 
native tissue USLS (i.e., ~60% “success”).69 A 2-sided logrank test with an overall sample 
size of 188 subjects (94 each group) achieves 80% power at a 0.05 significance level to 
detect a hazard ratio of 0.5188 when the proportion of those "surviving" (i.e. "successes") 
in the control group is 65% compared to 80% in the treated group, measured at 1 year. 
This presumes the accrual pattern across the study time period (3 years of accrual) is 
uniform. This N=188 already accounts for 25% either lost to follow-up or non-adherent 
to study cream in the control and treatment groups. Allowing for an additional 15% loss 
of participants from baseline to surgery, 222 total participants are needed. 
  
Potential problems & alternatives:  
Differences in baseline characteristics between the groups may occur by chance, but we 
will mitigate that risk by stratifying by clinical site, hysterectomy status, and duration since 
menopause (<10y & ≥10y). 
 
9.2.1 Treatment Assignment Procedures 
A randomized, double-blind, placebo-controlled trial design (CE cream versus placebo) 
will be used in this study.  SAS V9.3 will be used by the study biostatistician to generate 
the stratified, randomization lists.  Patients will be stratified by site, hysterectomy status, 
and duration since menopause (<10 and ≥10 years).  The randomization lists will be 
distributed to each site’s research pharmacy (or their designee).  Those conducting the 
primary and secondary measurements as well as the patients will be blinded to treatment 
assignment.  These data will not be housed in study’s database (i.e. REDcap).  
 
At the discretion of the primary investigators at any of the clinical sites, they may request 
the primary site PI to have the blind broken. The primary site PI—likely in consultation 

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33 
with the Safety Monitor, as needed—will then request this information of the DCC study 
database manager (permitting Dr. Hynan to remain blinded) if it is clinically needed to 
understand the medication that the patient is receiving. It is anticipated that this would only 
be requested for important medical reasons, e.g., a serious adverse event or significant 
allergic reaction to study cream. In most cases, patient skin irritation with cream application 
could prompt discontinuation of the study medication without unmasking. There is no plan 
for clinical site research pharmacists to unmask participants, research coordinators, or local 
site PIs directly. Planned breaking of the randomization codes will only be after all 
participants have reached the primary study outcome time point one year postoperatively; 
there are no plans for interim/ early data analyses. 
9.3 Interim analyses and Stopping Rules 
No analyses of efficacy are planned to be presented until the end of the trial. Additional 
DSMB review may be requested by the UTSW PI and biostatistician, and an emergency 
review by the DSMB requested at any time if questions of participant safety arise. 
Between-groups comparisons of safety variables will be presented to the DSMB.  
 
Should the DSMB decide to issue a recommendation to terminate or alter the study protocol 
based on safety, futility, or poor study performance (e.g., slow accrual, high loss-to-follow-
up, poor quality control) a full vote of the 3 site PI’s will be required.  Examples of findings 
that might trigger a safety review are the number of SAEs overall, the number of 
occurrences of a particular type of SAE, severe AEs/reactions, or increased frequency of 
events. Such findings are presented to the study biostatistician or to the Data and Safety 
Monitoring Board (DSMB) statistician to review the events by group to determine whether 
there are statistical as well as clinical concerns. The statistician reports the findings to a 
closed session of the DSMB or to the Safety Officer and/or NIA. The findings are used to 
determine what steps will be taken.  
9.4 Outcomes  
9.4.1 Primary outcome   
Aim 1. The primary outcome is dichotomous success/failure of prolapse repair (see Item 
9.1 above) as measured 12 months postoperatively. This is a composite outcome with 
failure defined by objective prolapse beyond the hymen, subjective sense of bulge by the 
patient, or retreatment by any intervention. It is not anticipated that any component of this 
primary outcome will require adjudication by committee. 
9.4.2 Secondary outcomes   
Aim 2: Quantify the effects of vaginal estrogen on symptoms of overactive bladder and 
urinary incontinence (Subaim 2a) and sexual function and dyspareunia (Subaim 2b) using 
validated questionnaires at regular intervals (Fig.3, Table 2) and assess for differences in 
rate of postoperative cystitis (Subaim 2c), and symptomatic vulvovaginal atrophy 
(Subaim 2d) 
TABLE 2. Questionnaires 
Description 

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34 
 
Subaim 2a (changes in overactive bladder symptoms) will draw from the relevant 
questions on from the PFDI-20 and PFIQ-7. Information on stress urinary incontinence 
will stem from the relevant questions (PFDI-20 and PFIQ-7) completed at baseline and at 
the Pre-op visit.  
 Use of CE cream and conversion of inelastic, avascular, thin epithelium to a thicker, 
well-rugated epithelium corresponding to decreased pH could reduce the incidence of 
postoperative cystitis (Subaim 2c), which is common after genitourinary surgery (14% 
after USLS, defined by +culture within 1mo post-op)84. This study will use a more liberal 
definition of post-op cystitis to include any prescription of antibiotics (culture-driven or 
empiric) for cystitis symptoms in the first postoperative month. 
Atrophy (and its resolution, Subaim 2d) will be queried at baseline, Pre-op, 6- and 
12-mo postoperatively using standardized questions about bother related to vaginal 
dryness, irritation/itching, soreness/pain, discharge, and dyspareunia (if sexually active); 
these symptoms are each scored as 1=not at all, 2=somewhat, 3=moderately, or 4=quite a 
bit bothersome.75 The most bothersome symptom (MBS) is also queried. On exam, a 
modification of the vaginal health composite score85 will have the examiner grade vaginal 
mucosal dryness, pallor, presence of rugae, and presence/absence of petechiae. The vaginal 
maturation index objectively categorizes percent of superficial, intermediate, and parabasal 
cells to be used as an index of patient adherence and to examine for correlation with 
symptom bother from other PFDs. 
 
Aim 3: Quantify histomorphology and connective tissue homeostasis of the vaginal wall 
in postmenopausal women with symptomatic prolapse undergoing surgical repair with or 
without pre- operative intravaginal estrogen therapy.  
Aim 3 Methodology:  
Pelvic Floor Distress Inventory 
(PFDI-20)73 (Aim 2a) 
There are 3 scales (urinary, POP, and colorectal-anal 
symptom distress inventories) including questions about 
incomplete bladder emptying, urinary frequency, 
urgency, and urge- and stress-associated incontinence 
Pelvic Floor Impact 
Questionnaire (PFIQ-7)73 (Aim 
2a) 
3 scales measure disease-specific impact on QoL 
(Incontinence, 
POP, 
and 
Colorectal-Anal) 
with 
questions about effect on physical activity, social 
activities, and emotional health. 
Pelvic Organ Prolapse/Urinary 
Incontinence Sexual Function 
Questionnaire (PISQ-IR)74 
(Aim2b) 
Specifically assesses the impacts of PFDs (urinary 
incontinence and POP) on sexual health and includes 
questions quantifying sexual desire, arousal, orgasm, 
satisfaction, and pain associated with intercourse. 
SF-12 
Validated, commonly-used QoL questionnaire assessing 
overall mental and physical health 
Patient Global Impression of 
Improvement & Severity (PGI-
I, PGI-S)70 
1-question tools validated for urinary incontinence and 
modified for POP. Assess overall impression of 
resolution of symptom bother and symptom severity 
related to POP. 

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35 
a. Vaginal wall biopsy:  Standardized full-thickness anterior apical vaginal wall biopsies 
will be obtained from all consenting participants at the time of prolapse repair. Biopsies 
from secondary clinical sites will be received in RNA preservative (RNAlater®). Although 
this buffer is excellent for preservation of RNA and facilitates dissection of biopsy material 
into various tissue components (e.g., muscularis from mucosa) and fixation of tissues after 
receipt, immunoblot analysis and enzymes assays are not possible. Thus, tissues obtained 
from only the primary site (UTSW) will be used to quantify protein and enzyme activity in 
addition to molecular analysis. Biopsies from all sites will be used for molecular and 
histopathology analyses. 
b. Rationale for study of candidate genes and proteins in the vaginal wall: The pelvic 
viscera are supported anatomically by the levator ani muscle complex and connective-
tissue attachments of the pelvic organs (aka the “endopelvic fascia”).86 The vagina’s 
support is commonly divided into apical (Level I), mid- (Level II), and distal (Level III) 
regions.87 The cardinal and uterosacral ligaments (Level I) have long been regarded as 
integral to the system of support of the pelvic organs88, and despite the name utero-sacral, 
this ligament interlaces and is contiguous with the upper vagina in more than two-thirds of 
women.89,90 Further, the connective tissue sheet enveloping the vagina suspends it to the 
levator ani via the arcus tendineous fascia pelvis (Level II).91 Dysfunction or disruption of 
one or more of these muscular, ligamentous, or connective tissue components leads to loss 
of support and, eventually, to POP. Importantly, the fibromuscular layer of the vaginal wall 
coalesces and is contiguous with the endopelvic fascia, and, thus, plays a role in the 
suspension of the vagina to the pelvic floor musculature. Work from the Word laboratory 
and others provides compelling evidence that the vaginal muscularis is abnormal in women 
with prolapse compared with age- and parity-matched asymptomatic controls with respect 
to smooth muscle proteins92, cellular composition93,94, ultrastructural abnormalities, and 
protease activity.95 Findings from other laboratories96-99, together with the known 
association between inherited elastinopathies and POP100-102, suggest that defective 
collagen or elastic fiber assembly (or increased degradation) is a primary and pivotal event 
in the pathophysiology of POP. 
 
Synthesis and assembly of collagen and elastin.   
a. Relative levels of mRNA for collagen types 1α1, 1α2, & 3, tropoelastin, LOX, LOXL-
1, and TGFβ will be quantified using qPCR and gene-specific primers which have been 
validated in the Word laboratory.  
b. Immunoblot analysis for Collagen types I and III will be conducted using samples from 
CE- and placebo-treated women and compared with expression in vaginal tissues from 
premenopausal women with normal vaginal support and premenopausal women with 
prolapse (samples in our existing biorepository).  Likewise, levels of tropoelastin, 
LOX, LOXL-1 and fibulins-3 and -5 will be quantified in urea-extracted matrix 
fractions from the mucosa (lamina propria + epithelium) and muscularis. This analysis 
will allow us to determine (i) the effect of menopause on expression of these matrix 
proteins in the vaginal wall, and (ii) if vaginal estrogen alters the connective tissue 
matrix. 
c. Collagen and elastin content will be analyzed using hydroxyproline and desmosine 
assays, respectively. The distribution of collagen (newly synthesized, denatured, or 
mature) will be analyzed in fractions of tissue extracts (i.e. supernatant of NaOH 

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36 
extraction as newly synthesized uncrosslinked or weakly crosslinked collagen; 
extraction of insoluble residue with 0.5 M acetic acid in which the supernatant 
represents denatured collagen and insoluble residue as crosslinked collagen). 
d. Histomorphology will be analyzed in detail. Specifically, we will use Hart’s staining 
to analyze elastic fiber morphology and content103, picrosyrius red stain to analyze 
collagen morphology and content103, thicknesses of epithelium, lamina propria, and 
muscular wall, and CD68 immunostaining to quantify macrophages. Macrophages may 
be important in POP since our pilot data indicate estrogen-induced downregulation of 
MMP12 (i.e., human macrophage elastase) in the vaginal wall. 
 
Matrix degradation. We hypothesize that certain collagenases (MMP-1 and -13), 
trypsinogens (PRSS3)104, and elastases (MMP-2, -9 and -12) and their respective inhibitors 
may be regulated by vaginal estrogen. We propose that postmenopausal women with POP 
will respond to estrogen therapy with decreased levels of MMPs (collagenases and 
elastases), decreased NTx (elastin degradative product) and decreased collagenase 
associated with collagen/elastin deposition relative to placebo-treated controls. Further, we 
propose that failure of reconstructive surgery will be associated with increased markers of 
collagenase and elastase activity.   
a. Collagenase activity will be determined using collagenase activity assays with FITC-
labeled soluble type-I collagen as substrate (Chondrex Inc. Redmond, WA). MMP-9 
and MMP-2 will be analyzed using quantitative gelatin zymography and endogenous 
active MMPs (-2,-9, -13) will be measured using active MMP fluorescent 
immunoassays (R&D Systems).  
b. The serine protease, PRSS3, will be analyzed using casein zymography, IHC, and 
immunoblot analysis.   
c. Levels of cross-linked collagen-type I N-telopeptides (NTx) will be used as an index 
of collagen degradation in biological fluids and tissues. NTx will be quantified in 
homogenates of mucosa and muscularis using competitive inhibition enzyme linked 
immunosorbent assays normalized to total protein (Oswteomark NTx Urine, Wampole 
Laboratories, Princeton, NJ).  
d. A cassette of signature protease inhibitors (cystatin C, SLPI, TIMP-1 and -2, and elafin) 
will be analyzed using qPCR and immunoblot analysis. 
e. Elastase activity in vaginal muscularis and mucosa will be determined using BODIPY-
FL-labeled DQ elastin conjugate that is highly labeled so that the fluorescence signal 
is quenched until enzymatic digestion yields highly fluorescent fragments (Molecular 
Probes).  We have experience with preparation of vaginal tissue for these assays. 
 
Vaginal smooth muscle.   
a. Relative levels of mRNA for smooth muscle α actin will be used as a marker for smooth 
muscle cells and myofibroblasts. Smooth muscle myosin heavy chain and h- and l-
caldesmon will be assessed as markers for the fully differentiated smooth muscle 
phenotype.92   
b. Immunoblot analysis for myosin heavy chain, caldesmon, and α actin will be conducted 
using samples from CE- and placebo-treated women and compared with expression in 
vaginal tissues from premenopausal women with normal vaginal support and others 
with prolapse (samples in our biorepository).92   

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37 
c. Histomorphology will be analyzed in detail. Specifically, we will use immunostaining 
for α actin and smooth muscle myosin heavy chain to analyze smooth muscle 
morphology and content.93,94 
 
Molecular profile of vaginal wall tissues (all clinical sites). High quality RNA from tissue 
samples obtained in this trial will facilitate a comparative analysis of gene expression 
related to matrix synthesis and degradation. It is not possible to analyze hundreds of genes 
involved in these pathways especially in ~392 (196 ea of muscularis and mucosa) tissues. 
We, therefore, choose to quantify mRNA levels of select genes related to matrix synthesis 
and degradation to determine a molecular profile of estrogen action in vaginal tissues. 
 Analysis of tissues from women enrolled in our pilot trial indicated that, of 7 genes 
important in collagen and elastin synthesis, the magnitude of estrogen-induced change was 
greatest and most consistent in Cola1 (6-fold). With increased numbers of subjects, we 
expect that vaginal estrogen will also result in increased LOX gene expression (which 
correlates with enzyme activity) in the vaginal muscularis.  Hence, we will utilize qPCR to 
measure relative levels of LOX and Cola1a mRNA as markers of collagen synthesis in all 
tissue samples from this trial. Col3 and tropoelastin will be used as potential negative 
controls and at least two housekeeping genes will be used as normalizers (h36B4 and 
GAPDH).  
 Our pilot trial indicated that mRNA levels for serine protease and MMP inhibitors 
were not regulated by vaginal estrogen. The single exception was the serine protease 
inhibitor, α1-antitrypsin, which tended to be increased in mucosal samples from women 
treated with estrogen (P=0.27). In contrast with protease inhibitors, 2 protease genes 
(MMP1 and MMP12), were significantly decreased in tissues from CE-treated women, and 
MMP9 activity was also downregulated dramatically in CE-treated women. Thus, MMP1, 
MMP12, and α1-antitrypsin will be quantified in all tissue samples using MMP2 and 
TIMP1 as negative controls.   
 This molecular profile will determine if collagen synthesis and degradation is 
regulated by vaginal estrogen. Nonetheless, MMP1 gene expression remained elevated in 
1 of 7 mucosal samples from women treated with CE. As shown in Fig.2 of this protocol, 
MMP9 was not universally downregulated in women treated with CE. These studies 
illustrate that estrogen-induced downregulation of matrix proteases may vary significantly 
among subjects. We will also quantify ERα and ERβ mRNA to test whether responses 
correlate with expression of estrogen nuclear hormone receptors in the vaginal wall and 
will use the well-known estrogen-responsive gene, VEGF, as an index of estrogen action 
in these tissues. 
 
Future Aim. 
From those participants consenting to an optional additional blood draw, 5mL (1 teaspoon) 
of whole blood will be obtained at baseline and stored in a typical yellow-top tube. This 
will be stored for possible future DNA analysis such as genetic analyses looking for genetic 
predictors of surgical success or failure.  
 

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38 
9.5 Data Analyses 
Aim 1. The primary outcome will be analyzed according to the assigned treatment group 
(modified intention-to-treat): i.e., all participants that are randomized and undergo a 
surgical prolapse repair and have at least one postoperative assessment will be analyzed 
according to their randomized assignment group. All eligible subjects who consent to the 
study and are enrolled will be available for analysis of baseline characteristics, and those 
that are randomized and use their study drug will be monitored for adverse events, but they 
must meet the additional qualifications above (i.e., undergo surgery and have a 
postoperative assessment) to be analyzed for the primary study outcome. At baseline, 
continuous measures will be compared between groups with Student’s t-test and chi-square 
(or Fisher’s exact test) for categorical measures. Scores from repeated surveys are 
continuous outcomes data and will be analyzed using repeated measures analysis of 
variance. We will test for interactions between time effect and treatment effect. For 
categorical data (e.g. prolapse stage), the analysis will be by categorical data modeling 
using weighted least squares and mixed logit models, with cross-sectional assessments (at 
specific time intervals) by chi-square. For missing follow-up points there are two possible 
approaches: (i) if there are few missing follow-up points, then their values may be imputed 
through multiple imputation methods, in which case repeated measures analysis of variance 
may be used following multiple imputation; (ii) more likely, we will make time a random 
effect and a mixed effects model with repeated measures will be applied. Time-to-event or 
event-free-time will be analyzed using survival methods to include the log-rank test and 
Cox regression. For measures that may not be assumed normal, the data will be transformed 
using a rank transformation prior to analysis.  
 
In accordance with NIH policy, we will include an analysis of the intervention effect (CE 
cream) performed by racial/ethnic subgroups, recognizing that the analyses will not have 
high statistical power for detecting clinically meaningful differences between races/ 
ethnicities. 
 
Aim 2 Outcomes. As above, continuous scores from repeated surveys will be analyzed 
using repeated measures analysis of variance with appropriate corrections made, as 
necessary, for missing data. 
Subaim 2a & 2b. Assuming a baseline UDI-6 score (obtained from the PFDI-20) of 
7.90±1.91 for the stress-incontinent subpopulation of IMPROVE (expected to be at least 
60%, or 67 participants per study arm)105, in order to demonstrate a clinically meaningful 
improvement (decrease) of 0.5(SD)106 to 6.95±1.91 using CE cream from baseline to time 
of surgery (preop), with 80% power and α 0.05, 65 participants are needed per arm. Further, 
to demonstrate an improvement in a baseline IIQ-7 score (obtained from the PFIQ-7) of 
9.67±7.14105 to 6.12±7.1, 64 participants are needed per arm (Subaim 2a). Similarly, to 
find a clinically important improvement (increase) in overall PISQ-12 score from baseline 
25.0±4.95 (women with prolapse107) to 27.48±4.95 at preop (or any postoperative time 
point), 64 participants are needed per arm (Subaim 2b). Thus, enrollment goals designed 
to address the primary aim (Aim 1) are sufficient to address these important secondary 
aims. 
Because midurethral slings and anticholinergic or beta-3 agonist medications are not 
excluded in study participants, these other interventions will clearly impact upon 

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39 
incontinence rates and will be controlled for in statistical comparisons between the two 
groups. Gross estimates of overactive bladder in the 2 groups will also be assessed by rates 
of anticholinergic or beta agonist use, as medication history will be queried at each patient 
encounter. Modest improvements in stress and overall urinary incontinence will be 
assessed from baseline to Pre-op (i.e. approximately 6-8wks local estrogen) using the 
relevant PFDI-20 and PFIQ-7 questions (see above Analyses) at both time points. 
 
Subaim 2c. Proportions of participants with postoperative cystitis will be compared using 
chi-square. Using the liberal definition of post-operative cystitis to include any patient 
prescribed antibiotics for cystitis symptoms, this study will have sufficient power to 
demonstrate an improvement from a 22% cystitis rate to 10% (80% power,α 0.05). The 
postoperative “MedSurg” history form (Form 15) queries whether there has been any 
interval occurrence of urinary tract infection (Item B4) and whether symptoms were treated 
empirically (i.e., no urine culture) or if culture-proven. 
 
Subaim 2d. Comparisons of vaginal maturation index and atrophy symptoms will use 
analysis of covariance, with treatment and study center as factors and baseline values as 
the covariate. 
 
Aim 3 Outcomes: If there is 10% loss of patients from randomization (baseline) to surgery, 
there will still be 100 patients per arm eligible for the standardized intraoperative apical 
anterior vaginal wall surgical biopsy. Our pilot trial (Section 2.2a, Humans) indicates 
sufficient power to determine 2-fold differences in collagen subtypes and MMP activity 
using tissues from UTSW. Further, with ~42 samples from UTSW (21 in each group), this 
will provide 80% power to also detect 2-fold differences in LOX protein and mRNA 
expression. All Aim 3 outcomes of interest (e.g. histological wall thicknesses, qPCR-
determined relative mRNA levels, collagen subtypes and elastic fiber content, collagenase 
and protease activity) will be summarized using the following statistics: mean, standard 
deviation, median, minimum and maximum. Additionally, because most biomarkers are 
not normally distributed, the geometric mean and standard deviation based on natural log 
transformed values will also be calculated. Summaries will be constructed by treatment 
group (CE vs. placebo) and comparisons conducted using 2-tailed Student’s t-tests 
comparing natural log transformed levels. Because this translational study (Aim 3) is 
considered to be descriptive and a relatively large number of markers are being considered, 
all p-values will be presented without adjustment for multiple comparisons and should be 
interpreted accordingly. We will correlate any treatment-group differences in vaginal wall 
or smooth muscle histomorphology, ERs, collagen gene expression, and protease 
downregulation with clinical outcomes, namely, objective or subjective “success” as 
outlined in Aims 1 and 2. 
 Ideally, CE cream application will support an improvement in prolapse recurrence 
success/failure rates 1y postop, but even if CE cream has a null or non-significant effect, 
the entire population will be divided into prolapse repair failures (cases) and successes 
(controls), and, controlling for CE cream exposure, univariate comparisons will be made 
of the continuous outcomes from Aim 3 (2-tailed Student’s t-tests). Those variables that 
attain a significance level of 0.1 or less in univariate analyses will be considered jointly in 
a multivariable backward stepwise logistic regression model. An accepted “rule of thumb” 

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40 
is that one needs 10 events (i.e. 10 cases of prolapse repair failure) for each predictor added 
to the model (i.e., for each degree of freedom).108,109 If a total of 67 cases are identified 
(i.e., 40% repair failure in 222 participants and 25% patient loss), this would be sufficient 
to analyze up to at least 7 variables in the multivariable model. Thus, we will identify 
important biomarkers that predict greater risk for failure of native tissue repair. These 
findings could theoretically be used to tailor the choice of surgical approaches for these 
higher-risk patients. 
10 
DATA COLLECTION AND QUALITY ASSURANCE 
10.1 Data Collection Forms 
Nurse research coordinators from each clinical site (UTSW, UAB, and WIH) will collect 
patient data captured by clinic providers and surgeons all blinded to study intervention 
using case report forms. Specimens (serum, whole blood, cytology specimens for vaginal 
maturation index, and standardized vaginal wall biopsies in women undergoing vaginal 
hysterectomy) will be processed by the research coordinators for secure shipment to 
UTSW, which will serve as the biorepository and site of analysis. Other data will be entered 
at each site using REDcap, a Web-based, HIPAA-compliant tool used by many major 
medical institutions. 
 
A set of electronic case report forms will be developed in REDCap following the order 
on existing paper forms.  Dropdowns or radio buttons based on allowable responses will 
be defined where possible. Ranges will be set for numeric values for notification of outliers. 
Each paper form will provide space for the following identifiers:  Site ID, Participant ID 
(anonymous patient study number), Study Visit Identifier, and Visit Date. The combination 
of Site / Participant ID will become the unique identifier for each subject in IMPROVE. 
When a visit packet is complete, the research coordinator will check each paper form for 
accuracy and completeness. A designated person will enter the data into REDCap. If any 
data are missing or questionable, the data entry operator will set the form status to 
“incomplete.” Once entry is complete, the entry operator will set the form status to 
“unverified.”  A second person will compare the entered data against the paper form. When 
all are correct, the reviewer will set the form status to “complete.” 
 
Refer to Manual of Procedures (MOP) for a complete inventory of Case Report Forms. 
10.2 Data Management  
REDCap has a data quality module, which will automatically report missing values, 
validation errors, and outliers. Additional project specific cross-checks defined by the PI 
will be designed and added to the REDCap data quality checks. Each site will be able to 
execute the rules and receive a list of discrepancies. Each error in the list has a direct link 
to the item in question, where it can be corrected or set to “exclude” from future reports.  
 
REDCap facilitates electronic form building and data collection. It has an automatic audit 
trail, report builder capability and data quality module. REDCap can export data to SAS, 
SPSS, R, STATA or Microsoft Excel. The IMPROVE REDCap database will reside on 

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41 
a secure UTSW server with continuous backup. Only authorized personnel with designated 
rights can access this study, and that at various levels. For example, a coordinator will be 
able to enter and check data, but cannot design screens. When used for a multisite project 
as with IMPROVE, an institution can be restricted to entering and viewing only its own 
data.  REDCap provides a protocol event schedule where specific forms are linked to 
events (visits) in the protocol. Authentication used in the REDCap application is 
compliant with the UT Southwestern Medical Center’s Health System password and 
security standards.  
 
Data Export: In the Data Export Tool menu, REDCap allows for selection of forms and/or 
specific data items to be exported for analysis.   
10.3 Quality Assurance  
10.3.1  Training 
Participating study surgeons must have performed ≥20 of each vault suspension 
(uterosacral ligament suspension and sacrospinous ligament fixation) procedure with 
≥5 in the 12 months before subject enrollment. 
 
All research personnel from the 3 clinical sites have completed the Collaborative IRB 
Training Initiative (CITI) Basic Course in Human Research Protections (or its 
equivalent), teaching in human subjects protection, and education in Good Clinical 
Practices (GCP) with maintenance certification of this training approximately every 3 
years. 
10.3.2 Quality Control Committee  
A quality control committee (as a function of the Steering Committee) will consist of 
the 3 clinical site PI’s and DCC biostatistician, which will convene at least twice 
annually to address any issues of study or data quality that emerge.  
10.3.3 Metrics 
Data Auditing: After data are audited (10% of the data packets selected randomly, more 
if the error rate is greater than 0%) by the study coordinator or designated individual, 
the status of the form will be set to “locked,” preventing further edits.  REDCap 
maintains an audit trail of all changes to the database. 
 
Tracking Reports: A set of reports will be implemented in REDCap to track accrual, 
withdrawals, adverse events, and overdue visits. 
 
10.3.4 Protocol Deviations 
Protocol deviations, i.e. unplanned instances of protocol noncompliance, will be 
captured using a report form (Form 21), which could be linked—as needed or 
appropriate—to any scheduled study visit. Potential deviations will be listed for the 
research coordinator to select (e.g., error in consenting, eligibility, randomization, 
study treatment administration, participant missing a scheduled visit, incomplete visit 

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42 
assessment, or other). Deviations will be reported to the site’s IRB. The circumstances 
of the deviation will also be captured on Form 21. 
 
Protocol deviations will be formally reviewed annually at each site’s IRB continuing 
review and also reviewed by the Quality Control Committee (10.3.2). 
10.3.5 Monitoring 
Local Institutional Review Board: Each site’s local IRB is charged in an annual 
continuing review process to assess for updates on the following:  
• reportable local and non-local AE’s and whether these should prompt updates 
to the informed consent document 
• participant tolerance of study procedures 
• participant accrual vs. withdrawal rates 
• errors in obtaining informed consent 
• rate and nature of protocol deviations and violations 
• participant complaints (if any) 
• changes in or new financial interests (and other potential conflicts of interest) 
of study personnel 
• DSMB reports 
• new or significant preliminary observations or descriptions of reports from 
outside trials that could be relevant to continuation of the study 
 
Further, each IRB may then request a plan to address these items including plans to 
increase enrollment, if necessary, in order to meet study objectives. 
 
Data Quality Monitoring: see also 10.2 and 10.3.3. REDCap has a data quality 
module, which will automatically report missing values, validation errors, and outliers. 
Additional project specific cross-checks defined by the PI will be designed and added 
to the REDCap data quality checks. Each site will be able to execute the rules and 
receive a list of discrepancies. Each error in the list has a direct link to the item in 
question, where it can be corrected or set to “exclude” from future reports.  
 
Other Quality Monitoring:  
• The DSMB will meet semi-annually (see 7.6) largely to evaluate the safety of trial 
participants but also with these broader charges: ensure confidentiality of data and 
the results of monitoring, report to the UTSW PI and biostatistician on the safety 
of participants, and make recommendations on continuation, termination, or  
modifications to the trial. 
• A Quality Control Committee (see 10.3.2) of the 3 clinical site PI’s will convene 
at least twice yearly to address issues of protocol noncompliance and data quality 
at the clinical sites. 

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43 
11 
PARTICIPANT RIGHTS AND CONFIDENTIALITY  
11.1 Institutional Review Board (IRB) Review 
This protocol and the informed consent document and any subsequent modifications will 
be reviewed and approved by the IRB or ethics committee responsible for oversight of the 
study. 
11.2 Informed Consent Forms 
The informed consent and the history and exam findings as detailed above will be 
collected in a private room. The informed consent will be written and provided in English 
or Spanish. A common template for the research informed consent form will be used by all 
of the clinical sites, modifying the content or format as necessary to meet the requirements 
of their respective institutional human subjects committees. This protocol must be 
approved by the IRBs at the clinical sites and DCC before implementation.  
Translator services are available at all study sites. Either the research coordinator or 
another member of the research team (PI or co-investigator) will be obtaining the consent, 
and the patient will sign and date/time her name to indicate understanding, which will be 
observed and countersigned by a witness. 
The consent form describes the purpose of the study, the procedures to be followed, 
and the risks and benefits of participation. A copy will be given to each participant or legal 
guardian and this fact will be documented in the participant’s record.  
11.3 Participant Confidentiality  
Included in the informed consent process is the addition of participant education as to 
procedures for maintaining confidentiality according to the Health Insurance Portability 
and Accountability Act (HIPAA). 
 
Any data, specimens, forms, reports, and other records that leave a clinical site will be 
identified only by a subject identification number (Subject ID) to maintain confidentiality.  
Only the research coordinators and the site PI will have access to the list linking medical 
record number to Subject ID. The investigational pharmacy staff at each clinical site will 
have knowledge of whether a patient received CE (Premarin) or placebo cream. The 
research coordinator and site PI will have the responsibility for securing original source 
documents containing any identifiable patient data. Each patient’s study documents will be 
kept in an individual binder, and these will be stored in a locked cabinet and office. 
Electronically, once these data are entered into REDCap (see above), only authorized 
personnel with designated rights can access this study. The IMPROVE REDCap database 
will reside on a secure UTSW server with continuous backup. Access to specimens 
collected locally or that arrives from consortium sites and stored at UTSW will be 
monitored and granted only by Drs. Rahn and Word.  
 
Information will not be released without written permission of the participant, except as 
necessary for monitoring by IRB, the FDA, the NIA, and the OHRP. 
11.4 Study Discontinuation  
The study may be discontinued at any time by the IRB, the NIA, the OHRP, the FDA, or 

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44 
other government agencies as part of their duties to ensure that research participants are 
protected.  
12 
ETHICAL CONSIDERATIONS 
This study will be conducted in accord with the U.S. Department of Health and Human 
Services’ (HHS) Office for Human Research Protections (OHRP) and the Human Subject 
Research (HRP) Code of Federal Regulations Title 45, Part 46 (i.e., 45 CFR 46). The 
current U.S. system for protection of human research subjects is heavily influenced by the 
Belmont Report of 1979, which outlines the basic ethical principles in research involving 
human subjects: (a) respect for persons, (b) beneficence, and (c) justice.   
Respect for persons respects an individual patient’s autonomy and clarifies that those 
with diminished autonomy require special protections. The IMPROVE study will require 
consent of subjects to volunteer for participation after adequate discussion of risks and 
benefits. If the autonomy of a participant comes into question (e.g., a previously 
autonomous participant develops diminished autonomy in the setting of delirium or 
dementia in an elderly patient), the participant may either be withdrawn from the study or 
continue only with the assent of the patient’s legal medical decision-maker (e.g., person 
with power of attorney). 
Beneficence describes an obligation to (i) do no harm, and (ii) maximize possible 
benefits/ minimize possible harms. The potential harms in IMPROVE are modest/ minimal 
as detailed in Section 7, but there will be vigilant surveillance for these potential adverse 
events, and treatments will be provided (or the study cream discontinued) when events 
occur. 
Justice addresses who ought to receive the benefits of research and bear its burdens. 
Importantly, as the IMPROVE study has the potential for benefit to participants, no 
restrictions are being made based on race, ethnicity, or language/ literacy. Further, in the 
selection of clinical sites to participate in IMPROVE, efforts were made to have a wide 
geographical, socioeconomic, and racial/ ethnic distribution of participants. 
13 
COMMITTEES 
Steering Committee: The IMPROVE Steering Committee has the primary responsibility to 
guide further revisions to the IMPROVE protocol and, ultimately, to insure that the 
protocol and study are conducted satisfactorily. This committee also oversees preparation 
of publications and will establish guidelines for authorship. Its membership is limited to 
the Principal Investigators from each clinical site, the primary site (DCC) biostatistician, 
and, at the discretion of the NIA, a representative program scientist. The Steering 
Committee will convene in person twice per year with additional teleconferences 
throughout the year. 
14 
PUBLICATION OF RESEARCH FINDINGS 
Publication of the results of this trial will be governed by the policies and procedures 
developed by the Steering Committee.  Any presentation, abstract, or manuscript will be 
made available for review by the sponsor and the NIA prior to submission. 

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45 
15 
REFERENCES 
1. 
Swift S, Woodman P, O'Boyle A, et al. Pelvic Organ Support Study (POSST): the 
distribution, clinical definition, and epidemiologic condition of pelvic organ support 
defects. Am J Obstet Gynecol 2005;192:795-806. 
2. 
Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ 
support in a general population of women: what is pelvic organ prolapse? Am J Obstet 
Gynecol 2003;189:372-7; discussion 7-9. 
3. 
Popovic JR, Kozak LJ. National hospital discharge survey: annual summary, 1998. Vital 
and health statistics Series 13, Data from the National Health Survey 2000:1-194. 
4. 
Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime risk of stress 
urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol 2014;123:1201-6. 
5. 
Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol 2005;106:615-34. 
6. 
Woodman PJ, Swift SE, O'Boyle AL, et al. Prevalence of severe pelvic organ prolapse in 
relation to job description and socioeconomic status: a multicenter cross-sectional study. 
International urogynecology journal and pelvic floor dysfunction 2006;17:340-5. 
7. 
Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ 
prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol 
2002;186:1160-6. 
8. 
Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittinghoff E, Brown JS. Cost of 
pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001;98:646-51. 
9. 
Cheon C, Maher C. Economics of pelvic organ prolapse surgery. International 
urogynecology journal 2013;24:1873-6. 
10. Hunskaar S, Burgio K, Clark A. Epidemiology of urinary and fecal incontinence and pelvic 
organ prolapse. In: Abrams P, Cordozo L, Khoury S, A. W, eds. Third international 
consultation on incontinence. 1st ed. Paris2005. 
11. Wu JM, Hundley AF, Fulton RG, Myers ER. Forecasting the prevalence of pelvic floor 
disorders in U.S. Women: 2010 to 2050. Obstet Gynecol 2009;114:1278-83. 
12. Handa VL, Garrett E, Hendrix S, Gold E, Robbins J. Progression and remission of pelvic 
organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol 
2004;190:27-32. 
13. Bradley CS, Zimmerman MB, Wang Q, Nygaard IE. Vaginal descent and pelvic floor 
symptoms in postmenopausal women: a longitudinal study. Obstet Gynecol 
2008;111:1148-53. 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
46 
14. Diwadkar GB, Barber MD, Feiner B, Maher C, Jelovsek JE. Complication and reoperation 
rates after apical vaginal prolapse surgical repair: a systematic review. Obstet Gynecol 
2009;113:367-73. 
15. Denman MA, Gregory WT, Boyles SH, Smith V, Edwards SR, Clark AL. Reoperation 10 
years after surgically managed pelvic organ prolapse and urinary incontinence. Am J 
Obstet Gynecol 2008;198:555 e1-5. 
16. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically 
managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-6. 
17. Iglesia CB, Sokol AI, Sokol ER, et al. Vaginal mesh for prolapse: a randomized controlled 
trial. Obstet Gynecol 2010;116:293-303. 
18. Sung VW, Rogers RG, Schaffer JI, et al. Graft use in transvaginal pelvic organ prolapse 
repair: a systematic review. Obstet Gynecol 2008;112:1131-42. 
19. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse 
in women. Cochrane Database Syst Rev 2013;4:CD004014. 
20. Murphy M. Clinical practice guidelines on vaginal graft use from the society of 
gynecologic surgeons. Obstet Gynecol 2008;112:1123-30. 
21. Jia X, Glazener C, Mowatt G, et al. Efficacy and safety of using mesh or grafts in surgery 
for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis. 
BJOG 2008;115:1350-61. 
22. Feiner B, Jelovsek JE, Maher C. Efficacy and safety of transvaginal mesh kits in the 
treatment of prolapse of the vaginal apex: a systematic review. BJOG 2009;116:15-24. 
23. Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Rogers RG. Incidence and 
management of graft erosion, wound granulation, and dyspareunia following vaginal 
prolapse repair with graft materials: a systematic review. International urogynecology 
journal 2011;22:789-98. 
24. van Geelen JM, Dwyer PL. Where to for pelvic organ prolapse treatment after the FDA 
pronouncements? : A systematic review of the recent literature. International 
urogynecology journal 2013. 
25. FDA Public Health Notification: Serious Complications Associated with Transvaginal 
Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
47 
Incontinence. 
2011. 
at 
http://www.fda.gov/medicaldevices/safety/alertsandnotices/ 
publichealthnotifications/ucm061976.htm.) 
26. Jia X, Glazener C, Mowatt G, et al. Systematic review of the efficacy and safety of using 
mesh in surgery for uterine or vaginal vault prolapse. International urogynecology journal 
2010;21:1413-31. 
27. Smith P, Heimer G, Norgren A, Ulmsten U. Localization of steroid hormone receptors in 
the pelvic muscles. Eur J Obstet Gynecol Reprod Biol 1993;50:83-5. 
28. Smith P, Heimer G, Norgren A, Ulmsten U. Steroid hormone receptors in pelvic muscles 
and ligaments in women. Gynecologic and obstetric investigation 1990;30:27-30. 
29. Moalli PA, Talarico LC, Sung VW, et al. Impact of menopause on collagen subtypes in the 
arcus tendineous fasciae pelvis. Am J Obstet Gynecol 2004;190:620-7. 
30. Jackson S, James M, Abrams P. The effect of oestradiol on vaginal collagen metabolism 
in postmenopausal women with genuine stress incontinence. BJOG 2002;109:339-44. 
31. Moalli PA, Klingensmith WL, Meyn LA, Zyczynski HM. Regulation of matrix 
metalloproteinase expression by estrogen in fibroblasts that are derived from the pelvic 
floor. Am J Obstet Gynecol 2002;187:72-9. 
32. Helvering LM, Adrian MD, Geiser AG, et al. Differential effects of estrogen and raloxifene 
on messenger RNA and matrix metalloproteinase 2 activity in the rat uterus. Biology of 
reproduction 2005;72:830-41. 
33. Hendrix SL, McNeeley SG. Effect of selective estrogen receptor modulators on 
reproductive tissues other than endometrium. Annals of the New York Academy of 
Sciences 2001;949:243-50. 
34. Goldstein SR, Neven P, Zhou L, Taylor YL, Ciaccia AV, Plouffe L. Raloxifene effect on 
frequency of surgery for pelvic floor relaxation. Obstet Gynecol 2001;98:91-6. 
35. Nygaard I, Bradley C, Brandt D. Pelvic organ prolapse in older women: prevalence and 
risk factors. Obstet Gynecol 2004;104:489-97. 
36. DeLancey JO, Morgan DM, Fenner DE, et al. Comparison of levator ani muscle defects 
and function in women with and without pelvic organ prolapse. Obstet Gynecol 
2007;109:295-302. 
37. Ismail SI, Bain C, Hagen S. Oestrogens for treatment or prevention of pelvic organ prolapse 
in postmenopausal women. Cochrane Database Syst Rev 2010:CD007063. 
38. Blakeman PJ, Hilton P, Bulmer JN. Oestrogen and progesterone receptor expression in the 
female lower urinary tract, with reference to oestrogen status. BJU international 
2000;86:32-8. 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
48 
39. Iosif CS, Batra S, Ek A, Astedt B. Estrogen receptors in the human female lower uninary 
tract. Am J Obstet Gynecol 1981;141:817-20. 
40. Smith P. Estrogens and the urogenital tract. Studies on steroid hormone receptors and a 
clinical study on a new estradiol-releasing vaginal ring. Acta obstetricia et gynecologica 
Scandinavica Supplement 1993;157:1-26. 
41. Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary 
incontinence 
in 
post-menopausal 
women. 
Cochrane 
Database 
Syst 
Rev 
2012;10:CD001405. 
42. Nelken RS, Ozel BZ, Leegant AR, Felix JC, Mishell DR, Jr. Randomized trial of estradiol 
vaginal ring versus oral oxybutynin for the treatment of overactive bladder. Menopause 
2011;18:962-6. 
43. Long CY, Liu CM, Hsu SC, Chen YH, Wu CH, Tsai EM. A randomized comparative study 
of the effects of oral and topical estrogen therapy on the lower urinary tract of 
hysterectomized postmenopausal women. Fertility and sterility 2006;85:155-60. 
44. Krause M, Wheeler TL, 2nd, Snyder TE, Richter HE. Local Effects of Vaginally 
Administered Estrogen Therapy: A Review. Journal of pelvic medicine & surgery 
2009;15:105-14. 
45. Simon JA. Identifying and treating sexual dysfunction in postmenopausal women: the role 
of estrogen. J Womens Health (Larchmt) 2011;20:1453-65. 
46. Nappi RE, Davis SR. The use of hormone therapy for the maintenance of urogynecological 
and sexual health post WHI. Climacteric : the journal of the International Menopause 
Society 2012;15:267-74. 
47. Krychman ML. Vaginal estrogens for the treatment of dyspareunia. The journal of sexual 
medicine 2011;8:666-74. 
48. Eriksen B. A randomized, open, parallel-group study on the preventive effect of an 
estradiol-releasing vaginal ring (Estring) on recurrent urinary tract infections in 
postmenopausal women. Am J Obstet Gynecol 1999;180:1072-9. 
49. Raz R, Stamm WE. A controlled trial of intravaginal estriol in postmenopausal women 
with recurrent urinary tract infections. The New England journal of medicine 
1993;329:753-6. 
50. Crandall C. Vaginal estrogen preparations: a review of safety and efficacy for vaginal 
atrophy. J Womens Health (Larchmt) 2002;11:857-77. 
51. Sturdee DW, Panay N. Recommendations for the management of postmenopausal vaginal 
atrophy. Climacteric : the journal of the International Menopause Society 2010;13:509-22. 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
49 
52. Felding C, Mikkelsen AL, Clausen HV, Loft A, Larsen LG. Preoperative treatment with 
oestradiol in women scheduled for vaginal operation for genital prolapse. A randomised, 
double-blind trial. Maturitas 1992;15:241-9. 
53. Karp DR, Jean-Michel M, Johnston Y, Suciu G, Aguilar VC, Davila GW. A randomized 
clinical trial of the impact of local estrogen on postoperative tissue quality after vaginal 
reconstructive surgery. Female pelvic medicine & reconstructive surgery 2012;18:211-5. 
54. Ashcroft GS, Ashworth JJ. Potential role of estrogens in wound healing. American journal 
of clinical dermatology 2003;4:737-43. 
55. Gilliver SC, Ashworth JJ, Ashcroft GS. The hormonal regulation of cutaneous wound 
healing. Clinics in dermatology 2007;25:56-62. 
56. Kingsberg SA, Wysocki S, Magnus L, Krychman ML. Vulvar and vaginal atrophy in 
postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment 
Options for Menopausal Vaginal ChangEs) survey. The journal of sexual medicine 
2013;10:1790-9. 
57. Shulman LP, Portman DJ, Lee WC, et al. A retrospective managed care claims data 
analysis of medication adherence to vaginal estrogen therapy: implications for clinical 
practice. J Womens Health (Larchmt) 2008;17:569-78. 
58. Balgobin S, Montoya TI, Shi H, et al. Estrogen alters remodeling of the vaginal wall after 
surgical injury in guinea pigs. Biology of reproduction 2013;89:138. 
59. Rahn DD, Good MM, Roshanravan SM, et al. Effects of Preoperative Local Estrogen in 
Postmenopausal Women with Prolapse: a Randomized Trial. The Journal of clinical 
endocrinology and metabolism 2014:jc20141216. 
60. Nelson RE, Grebe SK, DJ OK, Singh RJ. Liquid chromatography-tandem mass 
spectrometry assay for simultaneous measurement of estradiol and estrone in human 
plasma. Clinical chemistry 2004;50:373-84. 
61. Slayden OD, Hettrich K, Carroll RS, Otto LN, Clark AL, Brenner RM. Estrogen enhances 
cystatin C expression in the macaque vagina. The Journal of clinical endocrinology and 
metabolism 2004;89:883-91. 
62. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence 
and persistence, blood pressure, and low-density lipoprotein cholesterol: a randomized 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
50 
controlled trial. JAMA : the journal of the American Medical Association 2006;296:2563-
71. 
63. Bachmann G, Bouchard C, Hoppe D, et al. Efficacy and safety of low-dose regimens of 
conjugated estrogens cream administered vaginally. Menopause 2009;16:719-27. 
64. Minkin MJ, Maamari R, Reiter S. Improved compliance and patient satisfaction with 
estradiol vaginal tablets in postmenopausal women previously treated with another local 
estrogen therapy. International journal of women's health 2013;5:133-9. 
65. Bhavnani BR, Stanczyk FZ. Pharmacology of conjugated equine estrogens: efficacy, safety 
and mechanism of action. The Journal of steroid biochemistry and molecular biology 
2014;142:16-29. 
66. Reinke JM, Sorg H. Wound repair and regeneration. European surgical research 
Europaische chirurgische Forschung Recherches chirurgicales europeennes 2012;49:35-
43. 
67. Greenhalgh DG. The role of apoptosis in wound healing. The international journal of 
biochemistry & cell biology 1998;30:1019-30. 
68. Barber MD, Brubaker L, Menefee S, et al. Operations and pelvic muscle training in the 
management of apical support loss (OPTIMAL) trial: design and methods. Contemporary 
clinical trials 2009;30:178-89. 
69. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical 
approaches and perioperative behavioral therapy for apical vaginal prolapse: the 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
51 
OPTIMAL randomized trial. JAMA : the journal of the American Medical Association 
2014;311:1023-34. 
70. Yalcin I, Bump RC. Validation of two global impression questionnaires for incontinence. 
Am J Obstet Gynecol 2003;189:98-101. 
71. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic 
organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. 
72. Vaccaro CM, Mutema GK, Fellner AN, et al. Histologic and cytologic effects of vaginal 
estrogen in women with pelvic organ prolapse: a randomized controlled trial. Female pelvic 
medicine & reconstructive surgery 2013;19:34-9. 
73. Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life 
questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet 
Gynecol 2005;193:103-13. 
74. Rogers RG, Rockwood TH, Constantine ML, et al. A new measure of sexual function in 
women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse/Incontinence Sexual 
Questionnaire, IUGA-Revised (PISQ-IR). International urogynecology journal 2013. 
75. Bachmann G, Lobo RA, Gut R, Nachtigall L, Notelovitz M. Efficacy of low-dose estradiol 
vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Obstet 
Gynecol 2008;111:67-76. 
76. Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical 
and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet 
Gynecol 2000;183:1365-73; discussion 73-4. 
77. Weber MA, Limpens J, Roovers JP. Assessment of vaginal atrophy: a review. International 
urogynecology journal 2015;26:15-28. 
78. Pinkerton JV, Shifren JL, La Valleur J, Rosen A, Roesinger M, Siddhanti S. Influence of 
raloxifene on the efficacy of an estradiol-releasing ring for treating vaginal atrophy in 
postmenopausal women. Menopause 2003;10:45-52. 
79. Botsis D, Kassanos D, Kalogirou D, Antoniou G, Vitoratos N, Karakitsos P. Vaginal 
ultrasound of the endometrium in postmenopausal women with symptoms of urogenital 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
52 
atrophy on low-dose estrogen or tibolone treatment: a comparison. Maturitas 1997;26:57-
62. 
80. Freedman M, Kaunitz AM, Reape KZ, Hait H, Shu H. Twice-weekly synthetic conjugated 
estrogens vaginal cream for the treatment of vaginal atrophy. Menopause 2009;16:735-41. 
81. Barber MD, Brubaker L, Nygaard I, et al. Defining success after surgery for pelvic organ 
prolapse. Obstet Gynecol 2009;114:600-9. 
82. Chmielewski L, Walters MD, Weber AM, Barber MD. Reanalysis of a randomized trial of 
3 techniques of anterior colporrhaphy using clinically relevant definitions of success. Am 
J Obstet Gynecol 2011;205:69 e1-8. 
83. Nieminen K, Hiltunen R, Takala T, et al. Outcomes after anterior vaginal wall repair with 
mesh: a randomized, controlled trial with a 3 year follow-up. Am J Obstet Gynecol 
2010;203:235 e1-8. 
84. Chung CP, Kuehl TJ, Harris SK, et al. Incidence and risk factors of postoperative urinary 
tract infection after uterosacral ligament suspension. International urogynecology journal 
2012;23:947-50. 
85. Raymundo N, Yu-cheng B, Zi-yan H, et al. Treatment of atrophic vaginitis with topical 
conjugated equine estrogens in postmenopausal Asian women. Climacteric : the journal of 
the International Menopause Society 2004;7:312-8. 
86. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet 
Gynecol 1976;126:568-73. 
87. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet 
Gynecol 1992;166:1717-24; discussion 24-8. 
88. Campbell RM. The anatomy and histology of the sacrouterine ligaments. Am J Obstet 
Gynecol 1950;59:1-12, illust. 
89. Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JO. Quantitative analysis of 
uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet 
Gynecol 2004;103:447-51. 
90. Vu D, Haylen BT, Tse K, Farnsworth A. Surgical anatomy of the uterosacral ligament. 
International urogynecology journal 2010;21:1123-8. 
91. Word RA, Pathi S, Schaffer JI. Pathophysiology of pelvic organ prolapse. Obstetrics and 
gynecology clinics of North America 2009;36:521-39. 
92. Boreham MK, Miller RT, Schaffer JI, Word RA. Smooth muscle myosin heavy chain and 
caldesmon expression in the anterior vaginal wall of women with and without pelvic organ 
prolapse. Am J Obstet Gynecol 2001;185:944-52. 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
53 
93. Boreham MK, Wai CY, Miller RT, Schaffer JI, Word RA. Morphometric analysis of 
smooth muscle in the anterior vaginal wall of women with pelvic organ prolapse. Am J 
Obstet Gynecol 2002;187:56-63. 
94. Boreham MK, Wai CY, Miller RT, Schaffer JI, Word RA. Morphometric properties of the 
posterior vaginal wall in women with pelvic organ prolapse. Am J Obstet Gynecol 
2002;187:1501-8; discussion 8-9. 
95. Wieslander CK, Marinis SI, Drewes PG, Keller PW, Acevedo JF, Word RA. Regulation 
of elastolytic proteases in the mouse vagina during pregnancy, parturition, and puerperium. 
Biology of reproduction 2008;78:521-8. 
96. Yamamoto K, Yamamoto M, Akazawa K, Tajima S, Wakimoto H, Aoyagi M. Decrease in 
elastin gene expression and protein synthesis in fibroblasts derived from cardinal ligaments 
of patients with prolapsus uteri. Cell biology international 1997;21:605-11. 
97. Jung HJ, Jeon MJ, Yim GW, Kim SK, Choi JR, Bai SW. Changes in expression of fibulin-
5 and lysyl oxidase-like 1 associated with pelvic organ prolapse. Eur J Obstet Gynecol 
Reprod Biol 2009;145:117-22. 
98. Klutke J, Ji Q, Campeau J, et al. Decreased endopelvic fascia elastin content in uterine 
prolapse. Acta Obstet Gynecol Scand 2008;87:111-5. 
99. Takacs P, Nassiri M, Viciana A, Candiotti K, Fornoni A, Medina CA. Fibulin-5 expression 
is decreased in women with anterior vaginal wall prolapse. International urogynecology 
journal and pelvic floor dysfunction 2009;20:207-11. 
100. Milewicz DM, Urban Z, Boyd C. Genetic disorders of the elastic fiber system. Matrix 
biology : journal of the International Society for Matrix Biology 2000;19:471-80. 
101. Carley ME, Schaffer J. Urinary incontinence and pelvic organ prolapse in women with 
Marfan or Ehlers Danlos syndrome. Am J Obstet Gynecol 2000;182:1021-3. 
102. Klipple GL, Riordan KK. Rare inflammatory and hereditary connective tissue diseases. 
Rheumatic diseases clinics of North America 1989;15:383-98. 
103. Budatha M, Roshanravan S, Zheng Q, et al. Extracellular matrix proteases contribute to 
progression of pelvic organ prolapse in mice and humans. The Journal of clinical 
investigation 2011;121:2048-59. 
104. Budatha M, Silva S, Montoya TI, et al. Dysregulation of protease and protease inhibitors 
in a mouse model of human pelvic organ prolapse. PloS one 2013;8:e56376. 
105. Cho MK, Kim CH, Kang WD, Kim JW, Kim SM, Kim YH. Comparison of the clinical 
and quality-of-life outcomes after the inside-out TVT-O procedure with or without 

STU022015-117, Rahn, Form A3, Mod_11, 05-24-19 (2) 
 
54 
concomitant transvaginal gynaecological surgery. Journal of obstetrics and gynaecology : 
the journal of the Institute of Obstetrics and Gynaecology 2012;32:280-4. 
106. Crosby RD, Kolotkin RL, Williams GR. Defining clinically meaningful change in health-
related quality of life. J Clin Epidemiol 2003;56:395-407. 
107. Kim SR, Moon YJ, Kim SK, Bai SW. Changes in sexual function and comparison of 
questionnaires following surgery for pelvic organ prolapse. Yonsei medical journal 
2014;55:170-7. 
108. Long JS. Regression Models for Categorical and Limited Dependent Variables. California: 
Sage; 1997. 
109. Kleinbaum DG, Kupper LL, Muller KE. Applied Regression Analysis and Other 
Multivariate Methods. Boston: PWS-Kent; 1988.