Please select the eligibility criteria that correspond to the clinical trial below.
Title: Extended Pessary Interval for Care (EPIC Study): Patient Preference for 3 Verus 6 Month Follow-up
Brief Summary: Objectives: Pelvic organ prolapse (POP) is a common condition for which pessaries are commonly used in conservative treatment. Despite their prevalence, there is no literature to guide the management of pessaries. Our objective is to determine whether patients managed with a pessary for POP are more satisfied with follow-up at 3 or 6 month intervals and if there is any difference in complications rates between the two groups.

Hypothesis: The investigators hypothesize that there will be higher patient satisfaction in the group randomized to 6 month follow-up intervals and that there will be no difference in complication rates between the two follow-up groups.

Method: The investigators will conduct a prospective randomized control trial comparing patient satisfaction and complication rates between patients with pessaries randomized to either 3 or 6 month follow-up intervals over 1 year.


Options:
A: Inclusion Criteria:

Women:

* who are new attendees at outpatient gynaecology clinics with a primary complaint of prolapse;
* who have a prolapse of stage I to IV confirmed by their gynaecologist using the POP-Q grading system;
* who have a prolapse of one or more of the following types:
* anterior vaginal wall prolapse (urethrocele, cystocele,paravaginal defect);
* uterine/cervical prolapse;
* vaginal vault (after hysterectomy)prolapse;
* posterior vaginal wall prolapse (enterocele, rectocele, perineal deficiency);
* who require a vaginal pessary for treatment of their prolapse (the process of fitting the pessary will be according to standard practice at the centre thus the protocol for choice of pessary, insertion and follow-up will be determined locally);
* who successfully retain the vaginal pessary for two weeks after fitting;
* who are willing to participate in the study and to comply with their group allocation.

Exclusion Criteria:

Women:

* who wish surgical treatment for prolapse and wish to be immediately added to the surgical waiting list;
* who have had previous surgical treatment for prolapse;
* who have had a pessary fitted for treatment of prolapse within the last 12 months;
* who have had previous formal instruction in PFMT;
* who present with contraindications to either pessary or PFMT treatment;
* who are unable to comply with PFMT treatment;
* who have local atrophy (this must be treated first);
* who are less than 6-months postnatal;
* who are pregnant;
* who are unable to give informed consent.
B: Inclusion Criteria:

* Females with POP who have opted for conservative management with a pessary
* Able to read and write English
* First time pessary users
* Successful fitting with a covered ring or Gellhorn pessary, as determined at the usual early follow-up visit 2-4 weeks after initial fitting (successful defined as: no expulsion on movement, squatting or valsalva, no urinary retention, no discomfort, and still retained pessary after 2 weeks)
* Patients agree to use vaginal estrogen (either tablet or cream twice weekly) during the study period; patients may not use a vaginal estrogen ring since this requires changing every 3 months, and will interfere with the study follow-up schedule

Exclusion criteria:

* Current presence of vaginal bleeding, vaginal abrasions or ulcers, or vaginal infection
* Significant cognitive impairment
* Pessary used for indication other than POP (ie. urinary incontinence)
* Use of a pessary that is not a covered ring or Gellhorn (i.e exclude cube, donut, etc.)
* Contraindications to vaginal estrogen
* Unsuccessful pessary fitting (successful defined as: no expulsion on movement, squatting or valsalva, no urinary retention, no discomfort, and still retained pessary after 2 weeks)
C: Inclusion Criteria:

* Postmenopausal: no menses for \>1 year
* Minimum age: 48 years
* Symptomatic apical and/or anterior vaginal wall prolapse, stage 2 or greater
* No estrogen 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 1yr

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 oral or transdermal estrogen, SERM, or other medication impacting vaginal milieu
* History of vaginal irradiation
* Allergy to Premarin or its constituents
* Prior apical repair or use of mesh for prolapse repair
* Current tobacco use
D: Inclusion Criteria:

1. Symptomatic POP, stage II, stage III or stage IV
2. Postmenopausal women (patients with serum FSH\>40lu/L; or amenorrhea for 12 months)
3. Successfully fit with ring with support pessary
4. Ability to attend the clinical trial and follow-up
5. Patients and their families understand the study, are willing to participate for up to 1 year and can provide written informed consent
6. Willing and able to place vaginal cream

Exclusion Criteria:

1. Acute infection of internal genital tract
2. Hormone replacement therapy in recent 3 months
3. Suspected or untreated lower genital tract tumor
4. Genital fistula
5. Abnormally elevated intra-abdominal pressure (eg ascites, tumor, etc)
6. Life expectancy less than 1 year
7. Vaginal estrogen contraindications, including known or suspected estrogen dependent malignancies (endometrial carcinoma, melanoma), endometrial hyperplasia (thickness of endometrium≥5mm), thrombophlebitis or thromboembolic disease, undiagnosed irregular vaginal bleeding, known or suspected breast cancer, allergy to any component of the estrogen cream and severe liver disease, breast cancer
8. The volume of post-voiding residual is more than 250ml. -

Answer: B