The Women's EMPOWER Survey: Identifying Women's Perceptions on Vulvar and Vaginal Atrophy and Its Treatment

Genitourinary Syndrome of Menopause: Epidemiology, Physiopathology, Clinical Manifestation and Diagnostic

Genitourinary syndrome of menopause (GSM) is a term used to define a compilation of signs and symptoms arising from decreased estrogenic stimulation of the vulvovaginal and lower urinary tract. Among 27–84% of women in postmenopausal are affected for symptoms of GSM, and these can unquestionably impair health, sexual function, consequently the quality of life of these women. The main signs and symptoms of GSM include, among others, burning, irritation, vulvovaginal dryness, dyspareunia, urinary symptoms of urgency, dysuria, or recurrent urinary tract infection. The diagnosis can be made through anamnesis, questionnaires, physical exams, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be complemented by using the Vaginal Health Index (VHI), Vaginal Maturation Index (VMI), or vaginal pH measurement. The acknowledgment of this condition by health professionals is crucial for its identification and proper management and exclusion of other conditions that make a differential diagnosis with it.

Sexual health issues postpartum-A mixed methods study of women's help-seeking behavior after the birth of their first baby

OBJECTIVE

To identify women's help-seeking behavior in relation to sexual health issues after the birth of their first baby.

DESIGN

A mixed methods sequential explanatory study design was utilized. Phase one of the study consisted of a prospective cohort study to identify the help-seeking behavior of women experiencing sexual health issues at 3, 6, and 12 months postpartum. Phase two consisted of a qualitative descriptive design to explore women's help-seeking behavior for sexual health issues postpartum.

SETTING & PARTICIPANTS

The setting was a large urban tertiary referral maternity unit (greater than 8000 births per year) in the Republic of Ireland. Nulliparous women aged 18 years and over were invited to participate in phase one. Phase two consisted of a subsample of women who consented to being contacted for further research on admission to the study.

FINDINGS

Few women consulted a clinician for postpartum sexual health issues at each of the study's three, six and twelve month time-points. For example, only 2.9% (n=18) of women experiencing dyspareunia, and 3.6% (n=16) of those experiencing a lack of vaginal lubrication spoke to their General Practitioner (GP) about these issues at three months postpartum. The qualitative data supported the quantitative findings and suggested that even when women proactively sought help from healthcare professionals they were met with unhelpful responses. In the absence of support from practitioners, women became active agents and sought information from other women or the internet. In an effort to improve practice women recommended a greater focus on their physical and emotional recovery from birth.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Very few women consulted with a clinician about their experience of sexual health issues after birth. Findings will contribute to and assist policy makers in planning future postnatal services for women to include extending the final postnatal assessment beyond six weeks after birth.

Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM) occurs in approximately 50% of menopausal women but is both underrecognized and undertreated despite numerous treatment options. Vaginal dryness, irritation, dyspareunia, urinary frequency, and urinary urgency are some of the more common symptoms that can have a negative effect on women's lives and relationships. Treatment options can include over-the-counter moisturizers and lubricants that can be composed of water or silicone or have an oil base. However, women and health care providers need be aware of the effects of excipients in these products so that the therapy does not cause vaginal irritation. US Food and Drug Administration (FDA)-approved treatment options include vaginally administered estrogen products as well as dehydroepiandrosterone (prasterone) and the selective estrogen receptor modulator ospemifene. The prescription options have proven efficacy and safety and can be considered for use by women with a history of cancer following collaboration with the oncologist. Despite the FDA warning that recommends vaginal lasers not be used for vaginal rejuvenation, vaginal lasers have also been used as a treatment for GSM, but studies on their safety are limited. This article reviews GSM, including its impact, diagnosis, and treatment.

Squill oil for decreasing dyspareunia and increasing sexual satisfaction in menopausal women: A triple-blind randomized controlled trial

OBJECTIVE

The present study aimed to investigate the effect of squill oil on dyspareunia and sexual satisfaction in menopausal women.

MATERIALS AND METHODS

The present triple-blind randomized two-group controlled trial was conducted on 60 menopausal women (n=30 in placebo group and n=30 in squill oil group) in Mashhad in northeast of Iran in 2019. The Sabbatsberg Sexual Self-Rating Scale and Marinoff dyspareunia scale were the main tools used in this study. The participants were randomly assigned to two groups namely, squill oil group and placebo group and they received the treatments for 4 weeks. Questionnaires were completed before and 4 weeks after the intervention in both groups. Data analysis was performed using SPSS 24 by Mann-Whitney, t-test, and repeated measures ANOVA with a significance level of less than 0.05.

RESULTS

The average age in the squill oil group and placebo group were 53.5±2.2 and 51.7±4.5 years, respectively. There was a significant difference (p<0.001) between the two groups in terms of dyspareunia score before (1±3.6 vs 1±3.5) and after intervention (0.7±0.1 vs 1.2±1.2) in two groups.Results of independent t-test indicated that there was a significant difference (p<0.001) between the two groups in terms of sexual satisfaction before (23.4±5.7 vs 23.1±2.8) and after intervention (36.5±5.6 vs 24.8±2.5) in two groups.

CONCLUSION

Using squill oil can cause a reduction in painful sexual intercourse and an increase in sexual satisfaction in postmenopausal women.

Healthcare provider knowledge, attitudes, and preferences in management of genitourinary syndrome of menopause in the Mid-South

OBJECTIVE

This study explored the clinical management practices of healthcare providers who treat menopausal women in an urban Mid-South area. The study specifically examined their knowledge of prescribing and counseling related to the care of women who present with complaints or clinical findings of genitourinary syndrome of menopause.

METHODS

An electronic questionnaire was distributed to healthcare providers involved in the care of women undergoing menopausal transition spanning a variety of medical specialties. The questionnaire was distributed to academic program directors, coordinators, and ListServ administrators to forward to targeted respondents. Items included demographic questions, clinical knowledge, management practices, and preferences. Statistical analysis for associations between demographics was performed using Chi-squared tests and between age groups with Kruskal Wallis tests.

RESULTS

The final sample contained 106 healthcare providers. Respondents were demographically diverse and encompassed multiple levels of professional training including Attendings, Trainees (Residents and Fellows), as well as Advanced Practice Registered Nurses. Significant differences were noted in many areas examined in our questionnaire, comprising knowledge, management, counseling, and prescribing practices surrounding the treatment of genitourinary syndrome of menopause when accounting for training level, specialty, and years in practice. Among all respondents, 10.4% reported rarely or never discussing menopausal symptoms with their patients. Most respondents (76.4%) stated they had prescribed topical therapies for genitourinary syndrome of menopause, with over 90% of practitioners prescribing lubricants/moisturizers and estradiol cream; however, only 55% reported being familiar with the US Food and Drug Administration's boxed warning on low-dose vaginal estrogen. Nearly half of the respondents (49%) reported being uncomfortable counseling about the boxed warning on low-dose vaginal estrogen.

CONCLUSION

This study identifies gaps in Mid-South healthcare providers' awareness of the boxed warning on low-dose vaginal estrogen as well as their comfort level in providing counseling regarding the risks, benefits, and alternatives to vaginal estrogen. Integrated practice between physicians and Advanced Practice Registered Nurses can lead to a significant benefit to patients experiencing menopause as shared experience and knowledge are shared between each group. Our survey does reveal gaps in knowledge and practice for optimal outcomes for patients experiencing genitourinary syndrome of menopause. These results will be useful in providing continuing education to providers and more effective communication, evaluation, and treatment to patients.

The Prevalence of Sexual Dysfunction in Patients With Multiple Sclerosis in Cyprus: A Cross-sectional Study

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory and degenerative disorder of the central nervous system with significant immune participation. It can cause a variety of symptoms that may impact quality of life. This study investigates sexual dysfunction (SD) in patients with MS in Cyprus and compares it with a sample of the general population.

METHODS

The sample includes 107 patients with MS and 104 healthy controls. Recruitment was based on simple random sampling during their follow-up at a neurology clinic. Data collection for this study was carried out from May to September 2019.

RESULTS

Among patients with MS, 29.9% experienced SD symptoms (40.0% men and 23.9% women), whereas in the healthy population, the percentage with SD was 12.5%. Although 10 women with MS expressed SD symptoms, they did not categorize themselves as having sexual problems. Almost 90% of all patients reported that they have never been tested for SD.

CONCLUSION

Patients with MS have a higher rate of SD than the healthy control population, especially for the female population. There is a growing need for clinical advice on the issue of SD.

Genitourinary symptoms in women with breast cancer: what do oncology health professionals think and do about them?

OBJECTIVES

We aimed to improve understanding of health professional knowledge and management of genitourinary symptoms (GUS) in women with early breast cancer (EBC).

METHODS

A survey was sent to 872 health professionals caring for women with EBC. Questions addressed most common GUS seen, experience treating GUS, and attitudes to treatment options.

RESULTS

144 surveys were completed. Respondent characteristics: median age 50 years; 76% female; 42% medical oncologists; 24% nurses; 20% breast surgeons; 8% radiation oncologists. Most (68%) reported prescribing endocrine therapies for EBC, 99% were aware endocrine therapies can cause GUS, and 55% reported "often" or "always" asking patients on endocrine therapy if they have GUS. Respondents thought vaginal dryness was the most bothersome symptom for their patients (66%), followed by dyspareunia (11%). 81% of respondents reported seeing women stop endocrine therapy prematurely due to GUS. Respondents reported receiving "none" (19%) or "a little" (46%) training or education in managing GUS and only 16% reported feeling "very confident" managing GUS. The proportions of respondents reporting "often" and "very often" recommending the following vaginal treatments were: lubricants (81%); moisturisers (68%); oestrogens (21%); and laser (3%). Vaginal oestrogens were considered "safe" or "probably safe" by 77% and 90% of respondents for women with hormone receptor positive and negative EBC, respectively.

CONCLUSIONS

Despite health professionals frequently encountering GUS in women with EBC and seeing patients stop endocrine therapies prematurely, only 16% felt confident managing these symptoms. Education and training for health professionals are needed to better address this common problem.

Symptoms, attitudes and treatment perceptions of vulvo-vaginal atrophy in UK postmenopausal women: Results from the REVIVE-EU study

OBJECTIVES

To describe the attitudes and perceptions of postmenopausal women from the United Kingdom regarding menopause, vulvo-vaginal atrophy and its therapeutic management.

STUDY DESIGN

Post hoc analysis of the United Kingdom population from the REVIVE-EU Study.

MAIN OUTCOME MEASURES

The survey contained questions about women's knowledge of menopause and vulvo-vaginal atrophy symptoms, impact on their life and sexual activities, communication with healthcare professionals and treatments.

RESULTS

The most frequent symptom of menopause was hot flushes (75%). Vulvo-vaginal atrophy symptoms had a significant impact on participants' ability to enjoy sexual intercourse (66%), spontaneity (62%) and ability to be intimate (61%); however, only 68% of women had been to their healthcare professional for advice. Half of the sample expected that doctors would initiate a discussion of menopausal symptoms and sexual health, but was in fact rare (5%). Only 27% were under current treatment without a clear therapy pattern, of which 43% used vaginal over-the-counter treatments, 28% prescription (Rx), and 13% both. Efficacy was the main limitation for over-the-counter treatments, while for Rx products were side effects and safety. Women highlighted the restoring of the natural condition of the vagina as the main goal for a treatment (35%). Many United Kingdom women did not feel the need to see any healthcare professional for their gynaecological symptoms. Overall satisfaction with treatment was only 44%.

CONCLUSIONS

Vulvo-vaginal atrophy remains underdiagnosed and undertreated in United Kingdom. There is a lack of coherent discussion about vulvo-vaginal atrophy symptoms with clinicians. Many United Kingdom healthcare professionals could improve proactive communication with patients about vulvo-vaginal atrophy.

Incidence of venous thromboembolism among postmenopausal women prescribed ospemifene, selective estrogen receptor modulators for noncancer indications, or untreated vulvar and vaginal atrophy

OBJECTIVE

Ospemifene is a nonsteroidal selective estrogen receptor modulator (SERM) for the treatment of moderate symptomatic vulvar and vaginal atrophy (VVA) due to menopause. A postauthorization safety study is currently examining the incidence of venous thromboembolism (VTE) among postmenopausal women receiving ospemifene or other SERM (raloxifene, bazedoxifene, or tamoxifen, for noncancer indications), or with untreated VVA.

METHODS

This interim analysis used the US MarketScan Commercial and Medicare Supplemental claims database from 2013 to 2017 to identify incident VTE. The incidence rate and 95% confidence interval of VTE during the first continuous course of treatment (or continuous untreated time for the untreated cohort) were calculated for each cohort overall and by age group, with sensitivity analyses examining incidence in the short term (up to 90 days) and long term (all available follow-up, regardless of treatment changes).

RESULTS

Analyses included 8,188 ospemifene users, 11,777 other SERM users, and 220,242 women with untreated VVA. The incidence per 1,000 person-years and 95% confidence interval of VTE were 3.7 (1.7-7.1) for ospemifene, 11.5 (8.9-14.6) for other SERM, and 11.3 (10.8-11.7) for untreated VVA. Stratification by age and altering the time frame for analysis produced results with similar patterns to the primary analysis.

CONCLUSIONS

This interim analysis of an ongoing study suggests a favorable safety profile for ospemifene with respect to VTE. Comparative analyses with covariate adjustment will be performed when data accrual is complete.

The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society

OBJECTIVE

To update and expand the 2013 position statement of The North American Menopause Society (NAMS) on the management of the genitourinary syndrome of menopause (GSM), of which symptomatic vulvovaginal atrophy (VVA) is a component.

METHODS

A Panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on vaginal hormone therapies as well as on other management options available or in development for GSM. A search of PubMed was conducted identifying medical literature on VVA and GSM published since the 2013 position statement on the role of pharmacologic and nonpharmacologic treatments for VVA in postmenopausal women. The Panel revised and added recommendations on the basis of current evidence. The Panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Genitourinary syndrome of menopause affects approximately 27% to 84% of postmenopausal women and can significantly impair health, sexual function, and quality of life. Genitourinary syndrome of menopause is likely underdiagnosed and undertreated. In most cases, symptoms can be effectively managed. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of symptoms. These include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and the estrogen agonist/antagonist ospemifene. Long-term studies on the endometrial safety of vaginal estrogen, vaginal DHEA, and ospemifene are lacking. There are insufficient placebo-controlled trials of energy-based therapies, including laser, to draw conclusions on efficacy and safety or to make treatment recommendations.

CONCLUSIONS

Clinicians can resolve many distressing genitourinary symptoms and improve sexual health and the quality of life of postmenopausal women by educating women about, diagnosing, and appropriately managing GSM. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual patient, and patient preference. Nonhormone therapies available without a prescription provide sufficient relief for most women with mild symptoms. Low-dose vaginal estrogens, vaginal DHEA, systemic estrogen therapy, and ospemifene are effective treatments for moderate to severe GSM. When low-dose vaginal estrogen or DHEA or ospemifene is administered, a progestogen is not indicated; however, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data at present to confirm the safety of vaginal estrogen or DHEA or ospemifene in women with breast cancer; management of GSM should consider the woman's needs and the recommendations of her oncologist.

Topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: An EMAS clinical guide

INTRODUCTION

Vulvovaginal atrophy (VVA) is a chronic condition caused by estrogen deficiency. It affects around 50% of postmenopausal women, reducing their general and sexual quality of life as well as the quality of their personal relationships.

AIM

The aim of this clinical guide is to set out an individualized approach to the management of VVA with topical estrogens and non-hormonal preparations.

MATERIALS AND METHODS

Literature review and consensus of expert opinion.

SUMMARY RECOMMENDATIONS

An individualized approach is required for the management of VVA. Topical low-dose estrogens are effective and also alleviate urinary incontinence and prevent recurrent urinary tract infections. Women should not be denied long-term use of topical estrogens as long as they feel that this treatment is of benefit to them, because the safety data are reassuring. Non-hormonal preparations (lubricants and moisturizers) should be the first-line treatment for VVA in women taking adjuvant endocrine therapies for cancers considered to be hormone-dependent. They can be used over the long term.

Genitourinary syndrome of menopause: a systematic review on prevalence and treatment

IMPORTANCE

Genitourinary syndrome of menopause (GSM) consists of genitourinary tract symptoms that occur due to physical changes caused by estrogen concentrations decline after menopause. Unlike menopausal symptoms, which subside with time, GSM symptoms persist throughout a woman's life.

OBJECTIVE

This article aimed to systematically review the literature to investigate the prevalence of GSM and its treatment.

EVIDENCE REVIEW

The search was conducted in the electronic databases PubMed, CENTRAL, and EMBASE until October 2020. Eligible for the systematic review were studies and surveys conducted via questionnaires or medical interviews evaluating the existence of GSM symptoms with or without gynecological examination in postmenopausal women or women >40 years of age.

FINDINGS

After the application of predefined inclusion/exclusion criteria, 27 studies were included in the systematic review. The prevalence of GSM-related symptoms, such as vaginal dryness, irritation, itching, and dyspareunia, ranged from 13% to 87%. The use of GSM-specific treatment varied from 13% to 78%. Over-the-counter lubricants and moisturizers were the most popular therapeutic options (24.0%-85.5%), followed by low-dose vaginal estrogens (4.8%-35.0%). Vaginal health is not frequently discussed during doctor visits and awareness about the condition and the number of treatment options is low. Women are concerned about the long-term safety and side effects of hormonal treatment. The majority of women who suffer from genitourinary symptoms are dissatisfied by the treatment they have used.

CONCLUSIONS AND RELEVANCE

GSM is a highly prevalent condition among women. Nevertheless, women are frequently not aware of its cause and its treatment options. The findings of this review underline the need for education of patients and healthcare professionals regarding GSM diagnosis and treatment options.

Energy-Based Devices for Functional Vaginal Problems: Issues and Answers

Abstract

Vaginal rejuvenation is a marketing term that encompasses surgical and medical treatments for functional vaginal/vulvar problems including but not limited to genitourinary syndrome of menopause (GSM), sexual dysfunction, vaginal laxity, and stress urinary incontinence (SUI) and for esthetic concerns including dissatisfaction with vulvovaginal appearance. Multiple treatment options have become available for indications of functional vaginal problems. Noninvasive management options including the use of more novel treatments such as energy-based devices have gained interest. Previously, studies regarding the efficacy and safety of the energy-based devices for functional vaginal problems were mostly limited to cohort studies without sham treatment, control groups, randomization, or double blinding. As a result of this insufficient data in 2018, the FDA released a statement of warning against the use of energy-based devices in the treatment of functional vaginal problems or vaginal cosmetic procedures (Https://Www.Fda.Gov/Medical-Devices/Safety-Communications/Fda-Warns-Against-Use-Energy-Based-Devices-Perform-Vaginal-Rejuvenation-or-Vaginal-Cosmetic. 1–4, 2018).

Purpose of Review

This article reviews the most current treatment modalities in the realm of vaginal rejuvenation therapy with an emphasis on the efficacy and safety of the energy-based devices.

Recent Findings

In the most recent literature, there have been studies with improvements in study design that support the efficacy and the short-term safety of the energy-based devices.

Summary

More recent studies with improved study design evidence that the use of energy-based devices results in improvements in functional vaginal problems and that serious adverse events appear to be rare. The availability of these devices as treatment options for functional vaginal problems has the potential to impact patient by improving their symptoms and quality of life. Caution still remains however regarding their safety following a longer period of time after their use.

A Call to Change the Narrative on Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause affects up to 54% of postmenopausal women. Historically, women have been led to believe that symptoms such as vaginal dryness, dyspareunia, and vaginal itching were manifestations that they would just have to live with, but now, more than ever before, treatment options are available. More importantly, nurses are in a position to change the narrative of genitourinary syndrome of menopause by normalizing the conversation about menopause and its sequelae of genitourinary symptoms.

Evaluation of the efficacy of fractional CO2 laser in the treatment of vulvar and vaginal menopausal symptoms

PURPOSE

The objective of this study was to evaluate the efficacy of fractional CO₂ laser to manage vulvar and vaginal symptoms of Genitourinary Syndrome of Menopause (GSM) in postmenopausal women.

METHODS

All postmenopausal women with symptoms of GSM undergoing fractional CO₂ laser treatment in our centers were asked to fill out a validated quality of life questionnaire (Global Quality of Life Questionnaire), Visual Analog Scale (VAS) for symptoms, a questionnaire on overall discomfort related to pelvic floor symptoms, and the Female Sexual Function Index (FSFI) at several points: before each session (three sessions at monthly intervals) and one 3 months after treatment completion. Statistical analysis compared pre-therapy data and data at 3 months of treatment.

RESULTS

Forty-six women were included with a mean age of 57.3 years (± 11.1 years). A significant improvement was demonstrated in vaginal dryness (p = 6.34 10^-6) and for symptoms of stress urinary incontinence (p = 0.043). Among sexually active patients, there was a significant improvement in the degree of symptom discomfort affecting their satisfaction (p = 0.007), dyspareunia (p = 0.001) and sensitivity during sexual intercourse (p = 0.001). Significantly, more women were able to achieve (p = 0.026) and maintain (p = 0.018) lubrication during intercourse.

CONCLUSION

CO₂ laser treatment seems to improve the quality of life and sexual health of patients as well as GSM symptoms at 3 months of treatment; long-term reevaluation is necessary to demonstrate that improvement persists over time.

Physical characteristics and properties of estradiol softgel vaginal inserts

Objective:

TX-004HR is a low-dose estradiol (E2) softgel vaginal insert designed to be rapidly dissolving and mucoadhesive. This report describes the physical attributes and pharmacokinetic parameters of the softgel vaginal insert evaluated for the treatment of moderate to severe dyspareunia due to menopausal vulvar and vaginal atrophy.

Methods:

In vitro dissolution studies with 25-μg E2 inserts were performed and media samples were analyzed for E2 by high-performance liquid chromatography. Effects of body position on E2 bioavailability were assessed in a phase 1, randomized trial of the 25-μg softgel capsule versus a reference product in which women remained supine after dosing (n = 16), and in a substudy (n = 16) in which women were ambulatory or seated after dosing. Estradiol C_max, AUC_0-24, and t_max were measured by high-performance liquid chromatography-tandem mass spectroscopy. A phase 2, randomized study (n = 50) of 10-μg E2 versus placebo inserts assessed timing of capsule disintegration at days 1 and 15.

Results:

In vitro testing detected more than 80% of E2 in the dissolution medium by 15 minutes (first time point measured). In the phase 1 studies, baseline-corrected E2 plasma levels were not significantly different regardless of supine versus ambulatory/seated position after dosing: C_max, 24.1 versus 34.3 pg/mL; AUC_0-24, 77.6 versus 93.7 h · pg/mL; and t_max, 2.1 versus 1.9 hours, respectively. In the phase 2 study, no remnants of the softgel capsule were found at day 1 (6 hours) after dosing and day 15. Vaginal discharge was minimal (1/48 women; 2.1%).

Conclusions:

The presented data support rapid dissolution of the softgel capsule and similar E2 pharmacokinetic parameters regardless of body position after dosing.

Knowledge of genito-urinary syndrome of menopause among Italian gynecologists: the DIADEM survey

OBJECTIVE

The objective of this study was to present an updated picture of the knowledge and attitudes of Italian gynecologists with regard to the genitourinary syndrome of menopause (GSM).

STUDY DESIGN

An anonymous survey was sent via electronic mail to 3892 gynecologists. The survey consisted of 32 multiple-choice questions divided into four different areas: 1. general demographics of the respondents; 2. knowledge of GSM; 3. most frequently prescribed therapies; and 4. perception of patient compliance and satisfaction with current therapeutic options.

MAIN OUTCOME MEASURES

Knowledge of vulvo-vaginal atrophy (VVA) and attitudes of the gynecologists to its management.

RESULTS

Three hundred and seventy-four out of 3892 invited Italian gynecologists replied to the survey (response rate 9.7 %). Most (84 %) had a good knowledge of GSM and 74 % reported that they investigated it during clinic visits, but most of them underestimated its prevalence. The most frequently prescribed treatment was topical hormonal therapy (60 %), followed by vaginal moisturizers and lubricants (16 %), ospemifene (12 %) and systemic hormone therapy (12 %). According to the clinical experience of respondents, the most effective therapy is local hormonal therapy (36 %), followed by ospemifene (30 %). According to respondents, less than 50 % of patients continue therapy after 12 months, due to the discomfort in vaginal application, the cost of oral therapies and the fear of possible side-effects.

CONCLUSIONS

With the limitation of the low response rate, this study suggests that although Italian gynecologists who answered the survey had some knowledge of GSM, they underestimated its prevalence, did not know its most bothersome symptoms and had inadequate knowledge of the efficacy of treatments, patient compliance and satisfaction.

Estradiol softgel inserts for the treatment of VVA symptoms: an expert opinion

INTRODUCTION

Vulvar and vaginal atrophy (VVA) affects up to two thirds of postmenopausal women, with symptoms of vaginal dryness, dyspareunia, and vulvar/vaginal irritation. Despite the availability of various treatments, women express dissatisfaction with their options. An estradiol (E2; 4-µg and 10-µg) softgel vaginal insert was approved by the Food and Drug Administration (FDA) to treat moderate to severe dyspareunia, a symptom of VVA, due to menopause. These inserts were designed to treat VVA effectively and safely while avoiding some of the drawbacks of other administration methods.

AREAS COVERED

This article reviews the physical characteristics and pharmacokinetic data of the E2 softgel vaginal insert. Primary and secondary efficacy endpoints and safety data are reviewed from the pivotal REJOICE trial (NCT02253173), and substudies that explore response rates, changes in vaginal epithelium by visual assessment, efficacy in patient subgroups, effects on sexual function, and patient satisfaction compared with other treatments.

EXPERT OPINION

The E2 insert shows that vaginal drug delivery is an optimal route of administration for locally treating VVA. This E2 softgel vaginal insert is a safe and effective treatment for symptoms of postmenopausal VVA. The E2 insert's pharmacokinetic characteristics are related to its unique formulation, rapid dissolution, and minimal systemic absorption.

ABBREVIATIONS

AE: adverse event; AUC: area under the concentration-time curve; BMI: body mass index; C_avg: average concentration; CI: confidence interval; C_max: maximum concentration; C_min: minimum concentration; E2: estradiol; FDA: Food and Drug Administration; FSFI: Female Sexual Function Index; GSM: genitourinary symptoms of menopause: MBS: most bothersome symptom; NAMS: North American Menopause Society; OR: odds ratio; PI: pulsatility index; PK: pharmacokinetic; REVIVE: Real Women's Views of treatment options for menopausal Vaginal changEs; RI: resistance index; ROC: receiver operating characteristic; TEAE: treatment-emergent adverse event; t_max: time to maximum concentration; VVA: vulvar and vaginal atrophy.

Evaluation of a Discussion Guide to Promote Patient Understanding of Menopause and Informed Treatment Decision-Making

Background: Patient-provider communication surrounding menopause symptoms and treatment is often limited. We developed and evaluated a health literacy-appropriate discussion guide to support patient education. Materials and Methods: A cross-sectional randomized study was conducted among 100 English-speaking women, aged 45-60 years, in Chicago, IL, and Durham, NC. Participants were randomly assigned to review either the discussion guide or a standard education material (n = 50 per arm) and to complete an open book knowledge questionnaire; they then rated the appearance and quality of both materials. Bivariate analyses examined knowledge and satisfaction by study arm and across sociodemographic characteristics. Multivariable models tested the effectiveness of the discussion guide to improve knowledge compared with the standard material. Results: Women receiving the discussion guide demonstrated significantly higher knowledge scores compared with those who reviewed the standard material (mean [M] = 20.0, standard deviation [SD] = 2.7, vs. M = 18.1, SD = 2.6; p < 0.001); 82.0% of those exposed to the discussion guide correctly answered ≥85% of knowledge items compared with only 48.0% of those reviewing the standard material (p < 0.001). In multivariable analyses, participants receiving the discussion guide displayed significantly greater knowledge in comparison with those receiving the standard material regardless of whether knowledge was examined as a score (∝ = 1.9, 95% confidence interval [CI]: 0.9-2.9, p < 0.001) or 85% threshold (odds ratio: 5.7, 95% CI: 2.0-16.2, p < 0.001). More than two-thirds of women (68%) preferred the discussion guide; it was rated highly in terms of appearance and content. Conclusions: The discussion guide improved understanding of menopause symptoms and treatment options in comparison with a current standard and was well received by a diverse audience.

The MATE survey: men's perceptions and attitudes towards menopause and their role in partners' menopausal transition

Supplemental Digital Content is available in the text

Objective:

The perceptions and attitudes of menopause shared by men are largely unknown. This analysis characterized men's awareness and their understanding of their partner's menopausal transition.

Methods:

A 35-question, online survey was used to assess men's perceptions and attitudes toward menopause. Men were recruited from an online research marketplace and were eligible to participate if their female partners (45-64 years old) experienced ≥1 of the following symptoms: hot flashes, night sweats, sleepless nights, difficulty sleeping, low libido, mood swings, pain during sex, or vaginal dryness. Couples either lived together full time, or, if living separately, resided together regularly two or more times a week.

Results:

Of the 1,356 surveys sent to eligible men, 450 (33%) were completed. Most men were between 50 and 69 years (80%), married and not separated (90%), and lived with their partner full time (97%). Men were aware of the symptoms regularly experienced by their partner, with difficulty sleeping (54%) and lack of energy (49%) being frequently identified; these symptoms were attributed to menopause (26%) and/or aging (22%). Of those who were affected by symptoms (63%), most men reported they negatively impacted them (77%), their partners (70%), and relationships (56%). Men engaged in discussions with their partners regarding menopausal symptoms (72%) and believed they were somewhat/very influential (75%) in their partner's decision to seek treatment or make lifestyle adjustments.

Conclusions:

Overall, men are aware of their partner's menopausal transition and may influence decisions relating to symptom management. Educational interventions would further benefit men's awareness of menopause and available treatment options.

Video Summary:.

[Effectiveness of multimodal rehabilitation (biofeedback plus capacitive-resistive radiofrequency) on chronic pelvic pain and dyspareunia: prospective study and literature review]

OBJECTIVE

To determine whether a multimodal rehabilitation protocol (Biofeedback [BFB] plus capacitive-resistive [INDIBA®] radiofrequency [RF]) reduces pain and increases muscular strength in patients with chronic pelvic pain (CPP) and dyspareunia.

MATERIAL AND METHODS

We performed a prospective, quasi-experimental, before-after study in 37 patients with CPP and/or dyspareunia referred to the Rehabilitation Department of Hospital Universitario Santa Cristina (January 2016 to December 2018). The protocol consisted of 8 sessions of pelvic floor exercises assisted by manometric BFB (15min of tonic/phasic exercises each) supervised by a physiotherapist, followed by suprapubic and perineovaginal bipolar RF [capacitive(5 min)/resistive(10 min)]. The variables evaluated were pain (VAS 0-10) and strength (mmHg) of the pelvic floor musculature and the start/end of the treatment.

RESULTS

The mean age was 41.5±12.65 years. The prevalence was higher among women aged 21-40 years (n=20, 54%) and those aged 41-60 years (n=12; 32.4%). Dyspareunia was present in 34 patients (91.8%), and non-specific CPP in 3 (8.2%). The protocol improved pain (from 7.27±1.34 to 3.75±2.21 points), maximal muscular strength (from 25.56±15.9mmHg to 35.35±20.4mmHg) and mean muscular strength (from 4.86±3.53mmHg to 7.18±4.46mmHg) respectively (p<0.0001).

CONCLUSION

CPP and dyspareunia are a diagnostic challenge that requires multidisciplinary management. Treatment should be started early and should consist of distinct therapeutic modalities. The protocol of multimodal rehabilitation including BFB and capacitive-resistive RF reduces pain and improves strength in patients with CPP and dyspareunia.

Effective Prevention of Recurrent UTIs With Vaginal Estrogen: Pearls for a Urological Approach to Genitourinary Syndrome of Menopause

OBJECTIVE

To review the available data related to the prevention of recurrent urinary tract infection (rUTI) in postmenopausal women with vaginal estrogen preparations and provide the urologic community with the confidence to identify and treat genitourinary syndrome of menopause (GSM).

MATERIALS AND METHODS

A literature search of MEDLINE and the Cochrane Central Register of Controlled Trials databases was performed to identify studies utilizing vaginal estrogen in the treatment of urological conditions related to rUTI and GSM.

RESULTS

In the setting of untreated GSM, the etiology of rUTIs (at least 3 episodes of UTIs in 12 months or at least 2 episodes in 6 months) is not fully elucidated, but estrogen deficiency is a contributing factor. The diagnosis of GSM is primarily a clinical diagnosis supported by other objective findings including: a vaginal pH >5, decreased content of superficial cells, and/or increased proportion of parabasal cells on vaginal maturation index. Local vaginal estrogen, dehydroepiandrosterone (prasterone), and ospemifene are commonly used GSM treatments. Thirty-one trials were identified utilizing estrogen preparations for rUTI in postmenopausal women.

CONCLUSION

Overall, multiple randomized clinical trials have successfully been completed to show the efficacy of local estrogen preparations for the treatment of rUTIs. This high yield review provides a framework for assessing GSM, prescribing recommendations for local vaginal hormone preparations, and a summary of the substantial evidence supporting the new 2019 American Urological Association/Canadian Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Guidance for local vaginal estrogen use for rUTI.

Women's experience of vulvovaginal symptoms associated with menopause

OBJECTIVE

This study describes women's experiences of the genitourinary syndrome of menopause (GSM) elicited through focus groups and cognitive debriefing sessions during development of a novel patient-reported outcome measure (PROM) designed for use in both clinical care and research.

METHODS

A draft questionnaire to identify and assess bothersome genitourinary symptoms associated with estrogen deficiency in menopausal women was developed in five discrete phases from multiple sources of information in accordance with standards for PROM development. GSM was confirmed by report of symptoms in conjunction with a confirmatory pelvic examination and laboratory assessments.

RESULTS

Qualitative content interviews were completed in 36 menopausal women with GSM. Cognitive testing of draft PROM items was performed in nine focus groups, including 26 menopausal women with and 15 without GSM. Participants reported a range of symptoms and described associated impacts on more than 15 quality-of-life domains. The majority of women reported that their symptoms impacted their sexual functioning and had a negative effect on their overall quality of life. GSM affected many aspects of menopausal women's lives beyond sexual function, with descriptions of pain when walking, urinating, wearing tight clothes, and with other activities of daily living.

CONCLUSIONS

Women's own words methodically recorded and analyzed during qualitative interviews and cognitive debriefing focus groups illuminate the subjective experience of women with GSM. It is hoped that the PROM currently in development will provide an effective tool for increasing our understanding of the prevalence, predictors, and impact of GSM in menopausal women's lives.

Endometrial safety of low-dose vaginal estrogens in menopausal women: a systematic evidence review

OBJECTIVE

The aim of the study was to systematically review studies that evaluated endometrial hyperplasia or cancer incidence with unopposed vaginal estrogens.

METHODS

PubMed and EMBASE were searched from inception to August 2017 for relevant articles and abstracts. Bibliographies of review articles and abstracts of major women's health medical meetings were examined. Eligible studies (independently reviewed by 4 authors) had to report menopausal vaginal estrogen use and endometrial histology, or incidence of endometrial hyperplasia or cancer.

RESULTS

Of 5,593 abstracts from the literature search and 47 articles from other sources, 36 articles and 2 abstracts were eligible, describing 20 randomized controlled studies, 8 interventional studies, and 10 observational studies. Collectively, the studies did not support an increased risk of endometrial hyperplasia or cancer with low-dose vaginal estrogens. Rates of endometrial cancer and hyperplasia were 0.03% and 0.4%, respectively, from 20 randomized controlled trials (2,983 women) of vaginal estrogens. Overall, reports of endometrial hyperplasia were observed with various doses and durations and appeared sporadic (except 1.25 mg conjugated equine estrogens), consistent with endometrial hyperplasia rates in the general population. A Denmark registry study was an exception and may be of limited applicability to the United States. The Women's Health Initiative Observational Study showed no association (1.3 cases/1,000 women-years with vaginal estrogens versus 1.0/1,000 women-years for nonuse).

CONCLUSION

This systematic review supports the use of low-dose vaginal estrogens for treating vulvar and vaginal atrophy in menopausal women without a concomitant progestogen. This review does not support increased endometrial hyperplasia or cancer risk with low-dose, unopposed vaginal estrogens; however, longer-term, real-world data are needed.

Systemic estradiol levels with low-dose vaginal estrogens

OBJECTIVES

To critically evaluate published systemic estradiol levels during use of low-dose vaginal estrogens considering detection method and estrogen dose; describe challenges with accurately measuring estradiol; and determine the normal estradiol level range in postmenopausal women.

METHODS

PubMed was searched for studies reporting systemic estradiol levels with lower-dose vaginal estrogens (≤25 μg estradiol or 0.3 mg conjugated equine estrogens). Estradiol levels at baseline and during treatment, area under the curve, and maximum estradiol concentrations were summarized by dose within assay type. A proposed range of systemic estradiol in normal, untreated, postmenopausal women was estimated by conservatively pooling means and standard deviations from published studies.

RESULTS

Mean basal estradiol levels were 3.1 to 4.9 pg/mL using liquid or gas chromatography/mass spectroscopy (LC or GC/MS/MS) with a range of undetectable to 10.5 pg/mL using radioimmunoassay. Systemic estradiol levels with vaginal estrogens reflected their doses as measured with LC or GC/MS/MS in different studies: 7.1 to 9.1 pg/mL and 16.7 to 22.7 pg/mL with a 25-μg softgel capsule insert and a tablet insert, respectively; 4.6 to 7.4 pg/mL and 6.6 to 14.8 pg/mL with a 10-μg softgel capsule and a tablet insert, respectively; and 3.6 to 3.9 pg/mL with a 4-μg softgel capsule insert. A mean systemic estradiol concentration ranging from undetectable to 10.7 pg/mL is proposed as an estimate for basal estradiol levels in normal, untreated, postmenopausal women. Systemic estradiol absorption may be influenced by the placement of estradiol higher (as with an applicator) versus lower (as without an applicator) in the vagina, as estradiol transport to the uterus would be more likely further away than closer to the introitus.

CONCLUSION

Serum estradiol concentrations were generally lower when measured with more specific and sensitive assays. Estradiol absorption was dose-dependent, and may be influenced by dose, formulation, and positioning in the vagina. Very low systemic estradiol absorption with low/ultralow-dose vaginal estrogens may potentially decrease any adverse events that may be associated with higher doses of vaginal estrogens used for treating moderate to severe VVA due to less estradiol exposure.

Efficacy and safety of ospemifene in postmenopausal women with moderate-to-severe vaginal dryness: a phase 3, randomized, double-blind, placebo-controlled, multicenter trial

Objective:

To evaluate the safety and efficacy of ospemifene for the treatment of moderate to severe vaginal dryness in postmenopausal women with vulvovaginal atrophy (VVA).

Methods:

This 12-week, multicenter, double-blind phase 3 study randomized postmenopausal women (aged 40-80 years) with VVA and moderate to severe vaginal dryness as their most bothersome symptom to daily oral ospemifene 60 mg or placebo. Coprimary efficacy endpoints included changes from baseline to week 12 in percentages of vaginal parabasal and superficial cells, vaginal pH, and vaginal dryness severity with ospemifene versus placebo; other secondary endpoints were evaluated (weeks 4, 8, and 12). Safety was assessed by treatment-emergent adverse events (TEAEs) and endometrial biopsies.

Results:

Women (n = 631; ospemifene [n = 316], placebo [n = 315]) had a mean age of 59.8 years, a mean body mass index of 27.2 kg/m², and most were white. Ospemifene significantly improved (P < 0.0001) the percentages of parabasal and superficial cells, vaginal pH, and severity of vaginal dryness severity compared with placebo at week 12; significant between-group differences were noted by week 4. Secondary endpoints of dyspareunia (P < 0.001), maturation value (P < 0.0001), and the Female Sexual Function Index (P < 0.05) also significantly improved with ospemifene versus placebo at week 12. Significantly more women responded (31.5% vs 6.0%; P < 0.0001) or were satisfied (49.2% vs 33.8%; P = 0.0007) with ospemifene versus placebo at week 12. No unexpected TEAEs, treatment-related serious TEAEs, thrombotic events, or endometrial hyperplasia or carcinoma were observed.

Conclusions:

Ospemifene was effective and well tolerated for the treatment of moderate-to-severe vaginal dryness in postmenopausal women with VVA.

Practical Treatment Considerations in the Management of Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause is a condition comprising the atrophic symptoms and signs women may experience in the vulvovaginal and bladder-urethral areas as a result of the loss of sex steroids that occurs with menopause. It is a progressive condition that does not resolve without treatment and can adversely affect a woman’s quality of life. For a variety of reasons, many symptomatic women do not seek treatment and, of those who do, many are unhappy with their options. Additionally, many healthcare providers do not actively screen their menopausal patients for the symptoms of genitourinary syndrome of menopause. In this review, we discuss the clinical presentation of genitourinary syndrome of menopause as well as the treatment guidelines recommended by the major societies engaged in women’s health. This is followed by a review of available treatment options that includes both hormonal and non-hormonal therapies. We discuss both the systemic and vaginal estrogen products that have been available for decades and remain important treatment options for patients; however, a major intent of the review is to provide information on the newer, non-estrogen pharmacologic treatment options, in particular oral ospemifene and vaginal prasterone. A discussion of adjunctive therapies such as moisturizers, lubricants, physical therapy/dilators, hyaluronic acid, and laser therapy is included. We also address some of the available data on both the patient and healthcare providers perspectives on treatment, including cost, and touch briefly on the topic of treating women with a history of, or at high risk for, breast cancer.

An overview of dehydroepiandrosterone (EM-760) as a treatment option for genitourinary syndrome of menopause

Introduction: Dyspareunia caused by vulvovaginal atrophy is a primary symptom of genitourinary syndrome of menopause (GSM), a chronic, progressive medical condition that results from estrogen and androgen deficiency at menopause. Dehydroepiandrosterone (DHEA, prasterone) is an endogenous precursor steroid hormone that is metabolized into both androgens and estrogens that has been recently been approved by the FDA for the treatment of moderate to severe dyspareunia caused by vulvovaginal atrophy secondary to menopause.Areas covered: This is a comprehensive drug evaluation describing the chemical composition, pharmacokinetics, metabolism, clinical efficacy and safety of dehydroepiandrosterone (prasterone) in the treatment of dyspareunia and VVA secondary to menopause. Preclinical and clinical data suggesting further potential uses, benefits, and contraindications in the genitourinary health of postmenopausal women are also considered.Expert opinion: Intravaginal dehydroepiandrosterone (prasterone) is effective for the management of dyspareunia secondary to menopause and may be effective in the treatment of other types of sexual dysfunction that are secondary to menopause. Further studies should explore additional dosing regimens and different indications.

Ospemifene in the Management of Vulvar and Vaginal Atrophy: Focus on the Assessment of Patient Acceptability and Ease of Use

Endocrinological changes that occur with menopause lead to a chronic and progressive condition named vulvar and vaginal atrophy (VVA). This disease is characterized by symptoms such as dryness, dyspareunia, itching, burning, and dysuria. According to recent epidemiological studies, VVA has a high prevalence and can also occur in younger women prior to the menopause, negatively affecting quality of life, sexual function, intimacy and relationship with the partner. Accordingly, therapy should be effective, initiated early and continued for as long as possible. Up to recent years, available therapeutic options have included over-the-counter lubricants and moisturizers, vaginal oestrogens and systemic hormones. These products are not indicated for all women. Hormones are mostly contraindicated in women with a history of hormone-sensitive cancer and are frequently not accepted even by women without contraindications. Local therapies are frequently considered uncomfortable, difficult to apply, and messy. Indeed, these treatments have a high spontaneous discontinuation rate, mostly due to dissatisfaction, safety concern, side effects and difficulty in vaginal placement. Recently, ospemifene, a new non-hormonal systemic remedy, was approved by FDA (Food and Drug Administration) and EMA (European Medicines Agency) for the treatment of the two most bothersome symptoms of VVA: dryness and dyspareunia. Because ospemifene is a selective estrogen receptor modulator (SERM), it can be administered also in women with a history of breast cancer, and this makes it more acceptable by any woman. In addition, its route of administration minimizes those bothersome side effects intrinsic to the vaginal route of administration. Available data indicate that women using ospemifene have higher adherence to treatment, higher persistence and lower discontinuation rate. Satisfaction is higher than with other local therapies and overall health care cost is lower.

A systematic review of laser therapy for vulvovaginal atrophy/genitourinary syndrome of menopause in breast cancer survivors

Women who have been treated for breast cancer may experience vulvo-vaginal atrophy (VVA)/genitourinary syndrome of menopause (GSM). This is a progressive condition and will not improve without treatment. Whilst vaginal oestrogen is the most effective treatment for GSM, many breast cancer survivors and clinicians remain reluctant to use it. Laser therapy is emerging as an alternative treatment for this condition but there is little evidence available as to its value in this setting.

We undertook a systematic literature review to identify available evidence for the use of laser therapy for VVA in women with breast cancer. There are a number of small studies which suggest an improvement in vaginal health in this group. However, these are all small, non-randomised studies and there are a number of key questions which need to be answered before this treatment can be implemented into practice.

Early onset of action with a 17β-estradiol, softgel, vaginal insert for treating vulvar and vaginal atrophy and moderate to severe dyspareunia

OBJECTIVE

The softgel 17β-estradiol (E2) vaginal inserts (4 and 10 μg; Imvexxy; TherapeuticsMD, Boca Raton, FL) are FDA approved for treating moderate to severe dyspareunia associated with postmenopausal vulvar and vaginal atrophy (VVA). The objective here was to determine responder rates at week 2 and whether week-2 findings predicted week-12 responders in the REJOICE trial.

METHODS

Postmenopausal women received E2 vaginal inserts 4, 10, or 25 μg, or placebo for 12 weeks. Proportion of responders (having ≥2 of the following: vaginal superficial cells >5%, vaginal pH <5.0, or dyspareunia improvement of ≥1 category) were calculated. Odds ratios (ORs) for positive response at week 12 given a positive response at week 2 were determined in the efficacy evaluable (EE) population.

RESULTS

The responder rate (in EE population [n = 695]) was 74% to 82% with E2 inserts versus 24% with placebo at week 2, and 72% to 80% versus 33% at week 12. Positive treatment responses were 9- to 14-fold higher with vaginal E2 than with placebo at week 2, and 5- to 8-fold higher at week 12. Response at week 2 predicted response at week 12 in the total population (OR 13.1; 95% CI, 8.8-19.7) and with active treatment only (OR 7.9; 95% CI, 4.7-13.2).

CONCLUSIONS

A high percentage of postmenopausal women with moderate to severe dyspareunia responded with the E2 softgel vaginal insert at week 2, and a positive response at week 2 predicted a positive response at week 12.

Sexual functioning in 4,418 postmenopausal women participating in UKCTOCS: a qualitative free-text analysis

OBJECTIVE

Sexual well-being can contribute significantly to the overall quality of women's lives. This qualitative study aimed to examine sexual activity, functioning, and satisfaction in a large sample of postmenopausal women from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) METHODS:: Thematic analysis was used to evaluate the free-text data of the Fallowfield Sexual Activity Questionnaire (FSAQ) completed by UKCTOCS participants at baseline before annual screening.

RESULTS

A total of 24,305 women completed the baseline FSAQ and 4,525 (19%) provided free-text data, with 4,418 comments eligible for analysis. Median age was 64 years; 65% had a partner and 22.5% were sexually active. Four interrelated themes were derived: partner availability, physical and sexual health, mental well-being, and interpersonal relationships. Primary reason for absence of sexual activity was lack of a partner, mainly due to widowhood (n = 1,000). Women discussed how partner's medical condition (27%) or sexual dysfunction (13.5%), their own physical health (18%) or menopause-related symptoms (12.5%), and prescribed medication (7%) affected sexual activity. Impact of low libido in self (16%) or partner (7%), relationship problems (10.5%) or logistics (6%), and perceptions of ageing (9%) were also mentioned. Few (3%) referred to positive sexual experiences or had sought medical help for sexual problems (6%).

CONCLUSIONS

This qualitative analysis explored postmenopausal women's perspective on their sexual functioning. Having an intimate partner and good physical health are key factors for continuation of sexual activity and satisfaction. Further sexual education for healthcare professionals is needed to raise awareness about sexuality and sexual difficulties in later life. : Video Summary: Supplemental Digital Content 1, http://links.lww.com/MENO/A426.

Vaginal Health in Menopausal Women

The aim of this review is to provide an overview of genitourinary health in peri- and postmenopause, particularly of vulvovaginal atrophy (VVA), which is part of genitourinary syndrome (GSM). This condition has a high prevalence among post-menopausal women and negatively affects a woman's quality of life. Epidemiology, signs, symptoms, diagnostic criteria of VVA and target treatments for restoring vaginal health are discussed in light of the most recent literature. Issues related to this condition in menopausal women are under-diagnosed, lack objective diagnostic criteria, and consequently under-treated. Over the years, many treatments have been developed but their long-term effectiveness and safety have yet to be clearly defined. Patients are often dissatisfied and stop treatment, suggesting the need for a more personalized and tailored approach to achieve better compliance and thereby effectiveness. The aim of this paper is to provide an overview of the most recent literature on VVA in order to help the gynecologist in the management of this condition.

The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review

OBJECTIVE

The objective of this consensus document is to broaden the perspective on clinical management of genitourinary syndrome of menopause to include androgens.

METHODS

A modified Delphi method was used to reach consensus among the 14 international panelists representing multiple disciplines and societies.

RESULTS

Menopause-related genitourinary symptoms affect over 50% of midlife and older women. These symptoms have a marked impact on sexual functioning, daily activities, emotional well-being, body image, and interpersonal relations. Tissues in the genitourinary system are both androgen and estrogen-dependent. The clitoris, vestibule, including minor and major vestibular glands, urethra, anterior vaginal wall, periurethral tissue, and pelvic floor are androgen-responsive. Historically, treatment of postmenopausal genitourinary symptoms involved both androgens and estrogens. This subsequently gave rise to predominantly estrogen-based therapies. More recently, double-blind, placebo-controlled clinical trials have demonstrated that local vaginal dehydroepiandrosterone improves symptoms in postmenopausal women, including moderate to severe dyspareunia. Limited data suggest that systemic testosterone treatment may improve vaginal epithelial health and blood flow. Open-label studies that have used high doses of intravaginal testosterone in the presence of aromatase inhibitor therapy for breast cancer have resulted in supraphysiological serum testosterone levels, and have been reported to lower vaginal pH, improve the vaginal maturation index, and reduce dyspareunia.

CONCLUSIONS

Vaginal dehydroepiandrosterone, hypothesized to enhance local production of both androgen and estrogen, is effective for the management of dyspareunia in menopause. Vaginal testosterone offers potential as a treatment for genitourinary syndrome of menopause, but more studies are needed.

Vaginal pH: a simple assessment highly correlated with vaginal morphology and symptoms in postmenopausal women

OBJECTIVE

The aim of the study was to determine the utility of vaginal pH as a marker of menopause and vulvar and vaginal atrophy (VVA) before and after local estrogen treatment.

METHODS

Vaginal pH was determined using standard pH paper strips in two clinical trials involving postmenopausal women with signs and symptoms of VVA evaluated before and after intervention with vaginal estradiol in softgel capsules. The utility of vaginal pH was evaluated as a screening method for VVA due to menopause and correlations were analyzed between vaginal pH and VVA symptoms, physical changes, and maturation of the vaginal epithelium.

RESULTS

Changes in vaginal pH were significantly correlated with changes in superficial and parabasal cell counts; vaginal epithelial changes of color, integrity, thickness, and secretion; and the VVA symptoms of vaginal dryness and dyspareunia (vaginal pain with intercourse).

CONCLUSIONS

Vaginal pH consistently correlated with parabasal and superficial cells and the visual vaginal epithelial changes and symptoms of dryness and dyspareunia, and is thus a simple outpatient procedure that reflects the hormonal milieu and its effects on the vaginal epithelium.

Effects of ospemifene on genitourinary health assessed by prospective vulvar-vestibular photography and vaginal/vulvar health indices

OBJECTIVE

To prospectively evaluate the effects of ospemifene on the vulva and vagina in postmenopausal women using vulvar-vestibular photography and direct visual assessments.

METHODS

Postmenopausal women (aged 40-80 years) with moderate to severe vaginal dryness as their most bothersome symptom (MBS) were randomized to daily ospemifene 60 mg or placebo in this 12-week, multicenter, double-blind, phase 3 study. Vulvar-vestibular photographic images were captured at baseline and week 12 and were independently assessed with the Vulvar Imaging Assessment Scale (VIAS). Changes from baseline in Vaginal and Vulvar Health Indices (VHI and VuHI) with ospemifene versus placebo were analyzed at weeks 4, 8, and 12. Correlations between VIAS, VHI, and VuHI, with vaginal dryness severity and the Female Sexual Function Index (FSFI) scores were also assessed.

RESULTS

In all, 631 eligible participants were randomized (ospemifene 316, placebo 315) and included in the intention-to-treat population. Compared with placebo, ospemifene significantly improved total scores for VIAS (P = 0.0154), VHI (P < 0.0001), and VuHI (P < 0.0001) from baseline to week 12; significant VHI (P < 0.0001) and VuHI (P = 0.002) improvements were observed at week 4. Most VHI and VuHI individual items were significantly better with ospemifene versus placebo at week 12 (P < 0.05). Most correlations between the vulvovaginal assessment total scores versus vaginal dryness severity and FSFI scores were significant (P < 0.05).

CONCLUSION

Improvements observed in vulvovaginal health with ospemifene assessed by prospective vulvar-vestibular photography and other direct visual assessments support its efficacy in addition to the treatment of moderate to severe vaginal dryness due to menopause and the use of photographic and direct visual evaluations in future clinical trials.

VIDEO SUMMARY

Supplemental Digital Content 1, http://links.lww.com/MENO/A415.

Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause

Introduction: Vulvovaginal atrophy (VVA), a component of the genitourinary syndrome of menopause, is a progressive condition due to decline in estrogen leading to vaginal and vulvar epithelial changes. Accompanying symptoms of dryness, irritation, burning, dysuria, and/or dyspareunia have a negative impact on quality of life. Ospemifene is a selective estrogen receptor modulator (SERM) approved by the FDA for moderate to severe dyspareunia and vaginal dryness due to postmenopausal VVA. Areas covered: PubMed was searched from inception to March 2019 with keywords ospemifene and vulvar vaginal atrophy to review preclinical and clinical data describing the safety and efficacy of ospemifene for vaginal dryness and dyspareunia due to VVA. Covered topics include efficacy of ospemifene on vaginal cell populations, vaginal pH, and most bothersome VVA symptoms; imaging studies of vulvar and vaginal tissues; effects on sexual function; and safety of ospemifene on endometrium, cardiovascular system, and breast. Expert opinion: Ospemifene is significantly more effective than placebo in all efficacy analyses studied, working through estrogen receptors and possibly androgen receptors. Safety as assessed by adverse events was generally comparable to that with placebo and to other SERMs, and/or adverse events were not clinically meaningful. No cases of endometrial or breast cancer were reported.

Ospemifene versus local estrogen: adherence and costs in postmenopausal dyspareunia

Aim: Objective was to compare adherence and persistence, as well as direct healthcare costs and utilization, of ospemifene to available local estrogen therapies (LETs). Patients & methods: This retrospective database study used integrated medical and pharmacy claims data from the IQVIA Real-World Data Adjudicated Claims - US Database. Results: Ospemifene patients had significantly greater adherence and persistence compared with the other nonring LETs. Ospemifene had the lowest mean outpatient costs of any of the LET cohorts, including the estradiol vaginal ring. Total all-cause healthcare costs were also significantly less for ospemifene patients compared with all other LETs.

Sexual function and distress in postmenopausal women with chronic insomnia: exploring the role of stress dysregulation

OBJECTIVE

Menopause triggers changes in sexual function and many women develop sexual problems. Insomnia is common in postmenopausal women, and disturbed sleep has been linked to poor sexual health. Thus, postmenopausal women with insomnia may be especially vulnerable to developing sexual difficulties. This study estimated rates of sexual distress in postmenopausal women with chronic insomnia and explored associations between various facets of sexual health, insomnia symptoms, and insomnia-related stress dysregulation.

DESIGN

Cross-sectional.

SETTING

Large multi-site health system in the US.

PARTICIPANTS

150 postmenopausal women diagnosed with DSM-5 chronic insomnia disorder (56.44±5.64 years) completed measures of sexual distress, sexual function, hot flashes, insomnia symptoms, depression, and stress dysregulation in the forms of cognitive-emotional arousal (worry, rumination), sleep reactivity, and somatic hyperarousal.

RESULTS

Nearly half of the sample endorsed clinically significant sexual distress (46.9%). Insomnia symptoms were largely associated with poor sexual arousal, orgasmic dysfunction, sexual distress, and sexual dissatisfaction. Insomnia-related stress dysregulation was similarly associated with these facets of sexual health but was also linked to problems with low desire and greater vaginal pain during sex. Hot flashes and depression were negatively associated with sexual health.

CONCLUSION

Postmenopausal women with chronic insomnia endorse high rates of sexual distress. Although compromised sexual function appears directly related to poor sleep itself, our data suggest that stress dysregulation may play vital role in sexual problems endorsed by postmenopausal insomniacs, particularly regarding low desire and vaginal pain. Prospective research is needed to characterize the evolution of these co-occurring symptoms.

Vulvovaginal Discomfort Is Common in Both Premenopausal and Postmenopausal Women

OBJECTIVES

We surveyed women from a primary care population to assess the prevalence of unreported vulvovaginal symptoms.

MATERIALS AND METHODS

A random sample of women aged 18 to 84 years without a diagnosis of vulvovaginitis or vulvodynia in the past year were surveyed anonymously about prevalence and severity of vulvar and vaginal symptoms of itching, burning, irritation, vaginal discharge, vaginal dryness, and vulvovaginal pain in the past month. Women reporting at least 1 moderate-severe symptom were considered symptomatic. Demographic and clinical characteristics were compared between women with and without symptoms using Pearson's χ and Student's t test.

RESULTS

Of 1,676 mailed surveys, 272 (16.2%) were returned. Respondents were primarily non-Hispanic (254, 93.4%), White (214, 78.7%), and English speaking (267, 98.2%). More than a third of women (107, 39.3%) reported 1 or more moderate-severe symptoms. Symptomatic women were younger (49 ± 14 years vs 54 ± 15 years, p = .004) and more likely to report a history of asthma (22% vs 12%, p = .028), eczema or seasonal allergies (56% vs 40%, p = .011), or a previous diagnosis of bacterial vaginosis or yeast (36% vs 15%, p < .001) than asymptomatic women. Premenopausal versus postmenopausal women reported similar prevalence of moderate-severe symptoms: 57/136 (42%) vs 50/136 (37%), respectively (p = .39). Symptoms frequently or always interfered with both interest in sex (33/107, 31%) and ability to have sex (32/107, 30%).

CONCLUSIONS

This study suggests that moderate-severe vulvovaginal symptoms are prevalent in both premenopausal and postmenopausal women and that these symptoms have a significant impact on sexual health.