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Increased incident hip fractures in postmenopausal women with moderate to severe pelvic organ prolapse

Pal, Lubna MBBS, MRCOG, MS1; Hailpern, Susan M. DrPH, MS2,3; Santoro, Nanette F. MD4; Freeman, Ruth MD5; Barad, David MD, MS6; Kipersztok, Simon MD7; Barnabei, Vanessa M. MD, PhD8; Wassertheil-Smoller, Sylvia PhD2

doi: 10.1097/gme.0b013e31821b8484
Original Articles

Objective: The aim of this study was to examine the association between fracture and pelvic organ prolapse (POP) in postmenopausal women enrolled in the Women's Health Initiative Estrogen Plus Progestin trial.

Methods: POP was assessed as cystocele, rectocele, or uterine prolapse and was graded as either "absent to mild" or "moderate to severe." Cox proportional hazard analyses (adjusting for age, body mass index, race, asthma, emphysema, thyroid disease, family history of fracture, regular menses, age at menopause, nulliparity, history of hormone therapy [HT], history of falls, socioeconomic status, calcium, and vitamin D supplementation and physical activity) explored the relationships between moderate to severe POP and incident bone fractures.

Results: Moderate- to severe-grade POP was identified in almost 8% of women (n = 1,192). During a follow-up duration of 7.41 (2.18) years (mean [SD]), 2,156 incident fractures were observed; the most common fracture site was the lower arm (n = 615; 28.51%) followed by the hip (n = 205; 9.51%). Adjusted analyses confirmed moderate to severe POP (of any type) as an independent risk factor for incident hip fractures (hazard ratio [HR], 1.83; 95% CI, 1.16-2.89; P = 0.010). On analyses stratified by assigned treatment (HT vs placebo), moderate to severe rectocele emerged as an independent predictor of incident spine (HR, 2.61; 95% CI, 1.04-6.56; P = 0.042) and lower arm fractures (HR, 1.87; 95% CI, 1.06-3.29; P = 0.030) in the placebo group.

Conclusions: We identify moderate to severe POP (any type) in postmenopausal women as a risk factor for hip fracture; moderate to severe rectocele holds an additional risk of spine and lower arm fractures in women not taking HT.

Progestin Trial identify postmenopausal pelvic organ prolapse as a fracture risk. In light of these findings, the status of pelvic organ descent should be a consideration during fracture risk assessment in postmenopausal women.

From the 1Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT; 2Independent consultant; 3Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY; 4Department of Obstetrics and Gynecology, University of Colorado at Denver, Denver, CO; 5Department of Obstetrics and Gynecology & Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; 6Center for Human Reproduction, New York, NY; 7Shady Grove Fertility Center, Annapolis, MD; and 8Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee.

Received November 1, 2010; revised and accepted March 9, 2011.

This work was presented as an abstract at the annual meeting of The North American Menopause Society, Orlando, FL, September 24-27, 2008.

Funding/support: The Women's Health Initiative program is funded by the National Heart, Lung, and Blood Institute, US Department of Health and Human Services.

Financial disclosure/conflicts of interest: None reported.

Address correspondence to: Lubna Pal, MBBS, MRCOG, MS, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Reproductive Endocrinology & Infertility, Yale University School of Medicine, 333 Cedar Street, PO Box 208063, New Haven, CT 06520. E-mail:

©2011The North American Menopause Society