Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause

Role of Androgens in Female Genitourinary Tissue Structure and Function: Implications in the Genitourinary Syndrome of Menopause

INTRODUCTION

Genitourinary conditions in women increase in prevalence with age. Androgens are prerequisite hormones of estrogen biosynthesis, are produced in larger amounts than estrogens in women, and decrease throughout adulthood. However, research and treatment for genitourinary complaints have traditionally focused on estrogens to the exclusion of other potential hormonal influences.

AIM

To summarize and evaluate the evidence that androgens are important for maintaining genitourinary health in women and that lack of androgenic activity can contribute to the development of symptoms of the genitourinary syndrome of menopause.

METHODS

The role of androgens in the pathophysiology, diagnosis, and treatment of genitourinary syndrome of menopause was discussed by an international and multidisciplinary panel during a consensus conference organized by the International Society for the Study of Women's Sexual Health. A subgroup further examined publications from the PubMed database, giving preference to clinical studies or to basic science studies in human tissues.

MAIN OUTCOME MEASURES

Expert opinion evaluating trophic and functional effects of androgens, their differences from estrogenic effects, and regulation of androgen and estrogen receptor expression in female genitourinary tissues.

RESULTS

Androgen receptors have been detected throughout the genitourinary system using immunohistochemical, western blot, ligand binding, and gene expression analyses. Lower circulating testosterone and estradiol concentrations and various genitourinary conditions have been associated with differential expression of androgen and estrogen receptors. Supplementation of androgen and/or estrogen in postmenopausal women (local administration) or in ovariectomized animals (systemic administration) induces tissue-specific responses that include changes in androgen and estrogen receptor expression, cell growth, mucin production, collagen turnover, increased perfusion, and neurotransmitter synthesis.

CONCLUSION

Androgens contribute to the maintenance of genitourinary tissue structure and function. The effects of androgens can be distinct from those of estrogens or can complement estrogenic action. Androgen-mediated processes might be involved in the full or partial resolution of genitourinary syndrome of menopause symptoms in women. Traish AM, Vignozzi L, Simon JA, et al. Role of Androgens in Female Genitourinary Tissue Structure and Function: Implications in the Genitourinary Syndrome of Menopause. Sex Med Rev 2018;6:558-571.

Symptoms of menopause - global prevalence, physiology and implications

The symptoms of menopause can be distressing, particularly as they occur at a time when women have important roles in society, within the family and at the workplace. Hormonal changes that begin during the menopausal transition affect many biological systems. Accordingly, the signs and symptoms of menopause include central nervous system-related disorders; metabolic, weight, cardiovascular and musculoskeletal changes; urogenital and skin atrophy; and sexual dysfunction. The physiological basis of these manifestations is emerging as complex and related, but not limited to, oestrogen deprivation. Findings generated mainly from longitudinal population studies have shown that ethnic, geographical and individual factors affect symptom prevalence and severity. Moreover, and of great importance to clinical practice, the latest research has highlighted how certain menopausal symptoms can be associated with the onset of other disorders and might therefore serve as predictors of future health risks in postmenopausal women. The goal of this Review is to describe in a timely manner new research findings on the global prevalence and physiology of menopausal symptoms and their impact on future health.

The European Vulvovaginal Epidemiological Survey (EVES): prevalence, symptoms and impact of vulvovaginal atrophy of menopause

OBJECTIVES

The primary objective of the European Vulvovaginal Epidemiological Survey (EVES) was to assess, at a country level, the prevalence of postmenopausal women with vulvovaginal atrophy (VVA) confirmed by gynecological clinical assessment among all postmenopausal women attending menopause centers.

METHOD

Women aged 45-75 years old with their last menstrual period more than 12 months before and who attended menopause or gynecology centers were included. If they had at least one VVA symptom, women filled a number of questionnaires including the EuroQoL-EQ-5D3L and Day-to-Day Impact of Vaginal Aging (DIVA). Then a gynecological examination was performed to confirm the VVA diagnosis.

RESULTS

A total of 2160 evaluable patients were included in the study. VVA was confirmed in 90% of the patients. Compared with patients without confirmed VVA (n = 206), patients with confirmed VVA (n = 1954) were significantly older (p < 0.001), had more severe symptoms (p < 0.001 for vaginal and vulvar symptoms, p < 0.05 for urinary ones) and had a lower quality of life as assessed by EQ-5D3L (p = 0.012) and DIVA (p < 0.001).

CONCLUSION

VVA is highly prevalent among postmenopausal women. Gynecological clinical assessment of VVA is associated with severe symptoms and impaired quality of life and therefore should be promoted for appropriate clinical assessment and early therapeutic intervention.

Ablative dual-phase Erbium:YAG laser treatment of atrophy-related vaginal symptoms in post-menopausal breast cancer survivors omitting hormonal treatment

PURPOSE

First evaluation of dual-phase vaginal Er:YAG laser to omit hormonal treatment for atrophy-related symptoms in post-menopausal breast cancer survivors following prolapse surgery.

METHODS

Patients with a history of breast cancer at the time of surgery for pelvic organ prolapse were offered non-hormonal vaginal Er:YAG laser treatment when complaining of atrophy-related genitourinary syndrome of menopause. A single 10-min course of dual-phase protocol of pulsed Er:YAG laser (2940 nm, fractional ablative and thermal mode, fluence according to tissue thickness). Follow-up included subjective satisfaction, vaginal pH, vaginal health index (VHI), and complications after 6 weeks.

RESULTS

A total of 16 breast cancer survivors (age 71 years, SD 7) had been seeking treatment for pelvic floor symptoms related to vaginal atrophy at follow-up visits after prolapse surgery. All ablative vaginal Er:YAG laser outpatient procedures were successfully completed, all patients returned to daily activities without a need for analgetic medication. Evaluation was performed after 8.3 (SD 2.5) weeks. Pre-laser VHI scored 16 (SD 4.6) and post-laser VHI 20 (SD 3) with p = 0.01. Patients were satisfied in 94% (n = 15) regarding symptom relief.

CONCLUSIONS

Breast cancer survivors with atrophy-related complaints after pelvic floor surgery may benefit from vaginal application of this innovative dual protocol of Er:YAG laser technology as a non-hormonal treatment approach.

Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study

OBJECTIVE

To determine the prevalence of genitourinary syndrome of menopause (GSM) and urogynecological conditions associated with menopause, and to evaluate the impact of GSM on quality of life in a cohort of Spanish postmenopausal women.

METHODS

Multicenter, cross-sectional, and observational study involving 430 women.

RESULTS

The prevalence of GSM was 70%. GSM was diagnosed in 60.2% of women with no known diagnosis of vulvovaginal atrophy or GSM. Most prevalent symptoms were vaginal dryness (93.3%) and reduced lubrication with sexual activity (90.0%). Most prevalent signs were decreased moisture (93.7%) and loss of vaginal rugae (78.4%). GSM was significantly associated with stress or mixed urinary incontinence, overactive bladder, and vaginal prolapse. Symptoms showed a low-moderate impact on quality of life, mainly in sexual functioning and self-concept and body image.

CONCLUSIONS

The GSM is very prevalent in Spanish postmenopausal women, affecting up to 70% of those consulting the gynecologist. Despite the high prevalence of symptoms and signs and its impact on the women's well-being, GSM remains underdiagnosed and undertreated. Given its relationship with urogynecological conditions, it seems necessary to provide an adequate evaluation of postmenopausal women for identifying potential co-morbidities and providing most adequate treatments. An adequate management of GSM will contribute to an improvement in the quality of life of these women.

Treatment of vaginal atrophy with estriol and lactobacilli combination: a clinical review

In recent years, a vast quantity of clinical data has been accumulated on the pathophysiology of symptomatic vulvovaginal atrophy (VVA)/genitourinary syndrome of menopause (GSM) in peri- and postmenopausal women and on the treatment options for these conditions. Guidelines from several societies have recently been updated in favor of VVA/GSM vaginal therapy with the lowest possible doses of estrogens. The combination of a vaginal ultra-low dose of 0.03 mg of estriol (E3) and lyophilized, viable Lactobacillus acidophilus KS400 (0.03 mg-E3/L) is a unique product with a dual mechanism of action supporting not only the proliferation and maturation of the vaginal epithelium, but also restoration of the lactobacillary microflora. It has been demonstrated efficiently to establish and maintain a healthy vaginal ecosystem. Use of this combination considerably improves the clinical signs and symptoms as well as the quality of life of menopausal women suffering from vaginal atrophy. This combination therapy is well tolerated with a low overall incidence of side-effects and negligible estriol absorption. Based on recent scientific evidence and current treatment guidelines, the 0.03 mg-E3/L combination could be considered one of the options for the treatment of symptomatic vaginal atrophy in aging menopausal women.

Beneficial effects of pelvic floor muscle exercises on sexual function among postmenopausal women: a randomised clinical trial

Background The adverse effects of menopause on sexual function could be mitigated by pelvic floor muscle (PFM) training. This study aimed to investigate the effects of PFM exercises on sexual function in postmenopausal women.

METHODS

A randomised clinical trial was conducted among 97 Iranian postmenopausal women, aged 40 to 60 years. The participants' baseline sexual functions were assessed using the Female Sexual Function Index (FSFI) questionnaire. They were then randomly designated to two groups: (1) the intervention group, which received specific instructions on PFM exercises and was followed up on a weekly basis; and (2) the control group, which received general information on menopause. After 12 weeks, the sexual functions of the participants were reassessed.

RESULTS

No significant difference was initially observed between the two groups in terms of demographic and socioeconomic characteristics and total scores of FSFI. After the intervention, however, the scores of arousal, orgasm and satisfaction were significantly higher in the intervention group (3.10, 4.36, and 4.84 vs 2.75, 3.89, and 4.36 respectively; P<0.05).

CONCLUSION

PFM exercises have the potential to improve the sexual function of postmenopausal women and are thus suggested to be included in healthcare packages designed for postmenopausal women.

Early effect of fractional CO2 laser treatment in Post-menopausal women with vaginal atrophy

Background and Aim

Fractional CO₂ lasers have been shown to provide improvement of vulvovaginal atrophy (VVA). The aim of the current study was to assess the early effect of a fractional CO₂ laser system in treating postmenopausal women with clinical symptoms of VVA.

Methods

28 healthy post-menopausal women (mean age 60.1 ± 5.55 years) with VVA-related symptoms were treated with fractional CO₂ laser 3 times, in 4-week intervals. At each study visit, VHIS score and VVA symptom severity were recorded. Sexual function was assessed with the Female Sexual Function Index (FSFI).

Results

One month following the first laser treatment, the mean VHIS score was significantly improved (13.89 ± 4.25 vs. baseline 11.93 ± 3.82; p < 0.05), and improved further at 3 and 6 months following all three laser treatments (16.43 ± 4.20 and 17.46 ± 4.07, respectively). Almost all VVA symptoms were significantly improved at one month following the first treatment. A further significant improvement in VVA symptoms was noted at 3 and 6 months following the third laser treatment. Following treatments, the FSFI score increased significantly (22.36 ± 10.40 vs. baseline 13.78 ± 7.70; p < 0.05), and remained significantly higher than baseline at the 3- and 6-month follow-up visits.

Conclusion

CO₂ laser therapy for post-menopausal women can be considered an effective therapeutic option providing relief of symptoms already noted after one laser treatment.

A medical device containing purified bovine colostrum (Monurelle Biogel) in the treatment of vulvovaginal atrophy in postmenopausal women: Retrospective analysis of urinary symptoms, sexual function, and quality of life

OBJECTIVE

This study assessed the effectiveness and safety of a medical device containing purified bovine colostrum (Monurelle Biogel; Zambon, Bresso, Italy) in improving vulvovaginal atrophy (VVA), sexual function, urinary symptoms, and quality of life (QoL) in postmenopausal women.

METHODS

In all, 172 postmenopausal women with VVA were included in the study. All women were treated with vaginal Monurelle Biogel daily for 12 weeks. Patients underwent clinical examinations, completed a 3-day voiding diary, and had VVA graded using the Vaginal Health Index (VHI) at baseline and 12 weeks. Patients also completed the Female Sexual Function Index (FSFI), overactive bladder questionnaire (OAB-Q), and the Urogenital Distress Inventory (UDI-6), among others.

RESULTS

After 12 weeks, there were significant increases in mean (± SD) VHI (12.53 ± 3.67 vs. 19.31 ± 3.49; P < .0001), the number of patients engaging in regular sexual activity 102 (59.3%) vs. 144 (83.7%), and in the total FSFI score (21.64 ± 2.99 vs. 28.16 ± 1.93; P < .0001) compared with baseline. In addition, there were significant reductions in the mean number of 24-hour voids (9.57 ± 2.12 vs. 7.13 ± 1.22; P < .0001), urgent micturition episodes per 24 hours (1.75 ± 0.76 vs. 1.14 ± 0.87; P = .001), nocturia episodes (1.58 ± 0.85 vs. 0.97 ± 1.18; P = .0002), and urinary incontinence episodes per 24 hours (0.74 ± 0.59 vs. 0.28 ± 0.52; P = .003). Finally, after 12 weeks treatment, there were significant differences in UDI-6 (7.85 ± 0.81 vs. 5.56 ± 1.40), OAB-Q symptom (53.60 ± 12.57 vs. 22.08 ± 9.63), and OAB-Q health-related QoL (21.75 ± 8.51 vs. 69.34 ± 14.59) scores compared with baseline (P < .0001 for all). The Patient Impression of Global Improvement scale revealed global improvement in 143 women (83.14%).

CONCLUSIONS

Monurelle Biogel is an effective treatment for VVA in postmenopausal women, improving sexual life, urinary symptoms, and QoL.

Sexual Function in Women Suffering From Genitourinary Syndrome of Menopause Treated With Fractionated CO2 Laser

INTRODUCTION

Genitourinary syndrome of menopause (GSM) has a significant impact on the trophism of the genital and lower urinary tracts and can considerably impair sexual function. Fractional CO₂ laser has a regenerative effect on vulvovaginal tissue trophism after menopause.

AIM

To review the available literature on the effect of fractional CO₂ laser on the sexual function of postmenopausal women affected by GSM.

METHODS

A database search was carried out using the terms CO₂laser, vaginal atrophy, sexual function, dyspareunia, and genitourinary syndrome of menopause and excluding studies using other types of laser or including breast cancer survivors with vulvovaginal atrophy. For statistical analysis, the estimated overall laser effect was computed (when at least two studies were involved) and data type of generic inverse variance was computed using inverse variance as the statistical method, a random-effects model, and the difference in means as an effect measurement.

MAIN OUTCOME MEASURES

Different methods of evaluating sexual function were reported and studies were grouped and analyzed accordingly. Subjective assessment for dyspareunia was evaluated with a 10-point visual analog scale. Patient-reported outcome for an overall perception of sexual function was evaluated with a Likert scale. The Female Sexual Function Index was used as a condition-specific questionnaire.

RESULTS

Six articles were considered for this review. A total of 273 women (mean age = 57.8 years) were treated with the same protocol in all studies. Compared with baseline, at the end of the treatment, dyspareunia significantly decreased in severity (P < .001), and the patient's perception of overall sexual function showed a statistically significant improvement (P < .001). At the last follow-up visit, the Female Sexual Function Index score for each single domain and overall score was significantly better than at entry (P < .001).

CONCLUSION

Fractional CO₂ laser can improve sexual function in postmenopausal women affected by GSM by restoring a better trophism in the lower genitourinary tract. Salvatore S, Pitsouni E, Del Deo F, et al. Sexual Function in Women Suffering From Genitourinary Syndrome of Menopause Treated With Fractionated CO₂Laser. Sex Med Rev 2017;5:486-494.

Estetrol, a Fetal Selective Estrogen Receptor Modulator, Acts on the Vagina of Mice through Nuclear Estrogen Receptor α Activation

The genitourinary syndrome of menopause has a negative impact on quality of life of postmenopausal women. The treatment of vulvovaginal atrophy includes administration of estrogens. However, oral estrogen treatment is controversial because of its potential risks on venous thrombosis and breast cancer. Estetrol (E4) is a natural estrogen synthesized exclusively during pregnancy by the human fetal liver and initially considered as a weak estrogen. However, E4 was recently evaluated in phase 1 to 2 clinical studies and found to act as an oral contraceptive in combination with a progestin, without increasing the level of coagulation factors. We recently showed that E4 stimulates uterine epithelial proliferation through nuclear estrogen receptor (ER) α, but failed to elicit endothelial responses. Herein, we first evaluated the morphological and functional impacts of E4 on the vagina of ovariectomized mice, and we determined the molecular mechanism mediating these effects. Vaginal epithelial proliferation and lubrication after stimulation were found to increase after E4 chronic treatment. Using a combination of pharmacological and genetic approaches, we demonstrated that these E4 effects on the vagina are mediated by nuclear ERα activation. Altogether, we demonstrate that the selective activation of nuclear ERα is both necessary and sufficient to elicit functional and structural effects on the vagina, and therefore E4 appears promising as a therapeutic option to improve vulvovaginal atrophy.

Fractional CO2 laser therapy: a new challenge for vulvovaginal atrophy in postmenopausal women

OBJECTIVE

To evaluate the effects of CO₂ laser in the treatment of vulvovaginal atrophy (VVA) in postmenopausal women.

METHODS

VVA was assessed in 87 postmenopausal women (mean age 58.6 ± 6.9 years) before and after the treatment. The protocol consisted of three monthly treatments and included the treatment of vulva. Subjective measures included VAS (Visual Analog Scale) both for vaginal dryness and dyspareunia; DIVA (Day-by-day Impact of Vaginal Aging); a questionnaire on treatment satisfaction and one about the degree of pain during the procedure. Objective measures included VHI (Vaginal Health Index) and VVHI (Vulvo-Vaginal Health Index). Time points of the study were at the screening visit (T0), at baseline (T1), at week 4 (T2), at week 8 (T3), after 3 months since the last laser application (T4), after 6 months (T5), after 9 months (T6), after 12 months (T7) and after 15 months (T8).

RESULTS

Treatment induced significant improvement in the VAS score. After treatment, VHI and VVHI indicated no VVA and this improvement was long lasting. Multivariate analysis showed that the time of follow-up was correlated with better VHI and VVHI (p < 0.001). DIVA improved over time (p < 0.001).

CONCLUSIONS

This study shows that CO₂ laser treatment induces a significant and long-lasting improvement of symptoms.

Role of Vitamin D in urogenital health of geriatric participants

INTRODUCTION

Role of Vitamin D is very well known for the functioning of many body organs. However, its role in the postmenopausal women in relation to various genitourinary disorders has been recognized recently. The main objective of this study was to evaluate role of Vitamin D in vaginal health, prolapse, bladder and bowel function, and bacterial vaginosis (BV).

MATERIALS AND METHODS

This was a randomized controlled study in which 200 geriatric female patients of 65-78 years of age divided into two groups comprising study and control group with 100 participants in each. Detailed obstetrical, gynecological, and clinical history was elicited. Detailed examination regarding the prolapse, urinary and bowel functions, and bacterial infections was done followed by follow-up of 3 and 6 months each. Chi-square and independent t-test used for data analysis.

RESULTS

Mean modified vaginal health index (MVHI) among patients with pelvic floor diseases was statistically significant with P = 0.0472. There was a visible increasing trend in Vitamin D deficiency with increase in time since menopause (P = 0.1193). Patients with pelvic floor disease had mean Vitamin D statistically significant with P = 0.0462. With increase in Vitamin D levels, MVHI was found to be better. The association of mean Vitamin D levels among patients with urinary incontinence as compared to controls was significant with P = 0.0460. Association of mean Vitamin D levels in patients with fecal incontinence and BV as compared to controls was not statistically significant with P = 0.6304 and 0.79, respectively. Low Vitamin D levels were associated with high mean parathyroid hormone (PTH) levels statistically significant with P = 0.034. MVHI was found to increase significantly with Vitamin D supplementation at 3 and 6 months' follow-up. There was increase in Vitamin D and calcium levels and fall in serum PTH levels at 3 and 6 months.

CONCLUSIONS

Vitamin D levels were associated with a decreased risk of pelvic floor disorders, improved MVHI in women in geriatric age group.

Macro-regional variation in attitudes toward and experiences of vulvar and vaginal atrophy among Italian post-menopausal women: a post hoc analysis of REVIVE survey data

Italian participants in the European REVIVE survey reported that vaginal and vulvar atrophy (VVA) impaired various aspects of their lives, notably the ability to enjoy sex. The aim of the present study was to explore regional differences in knowledge, experiences, and treatment of VVA in the Italian REVIVE sample (n = 1000), which was analyzed according to region of residence. While many respondents were unfamiliar with the VVA condition, most could relate their VVA symptoms to the menopause. The rate of diagnosis of VVA was twice as high in Central Italy as in the North-East. For individual VVA symptoms, 25.4-41.6% of respondents judged that the symptom had worsened over time. There were no significant regional differences for symptoms in terms of reported rate, change in severity, impact on sexual activity, or health-care visits. Testosterone cream and OTC medication based on hyaluronic acid showed significant regional differences in lifetime rates of use. In Italy, there are modest regional differences in knowledge, diagnosis, and treatment of VVA, some of which may be explained by inter-regional differences in health care. Further efforts are needed to ensure that Italian women are properly informed about VVA and have access to appropriate health care and treatments.

A Dermatologist’s Approach to Genitourinary Syndrome of Menopause

Background:

Genitourinary syndrome of menopause (GSM) is a debilitating condition caused by hypoestrogenism that presents with vaginal dryness and dyspareunia as well as other genital, sexual, and urinary symptoms. Previously known as atrophic vaginitis, the term GSM is now used.

Objective:

To help familiarise dermatologists with diagnosing and managing GSM.

Methods:

In total, 218 articles were identified and reviewed by 2 independent authors using PubMed. Articles included were from December 2005 to December 2015. Sixty-seven articles met our inclusion criteria.

Results:

GSM is a clinical diagnosis, requiring the presence of symptoms that should be bothersome and not accounted for by another condition. A pH test may help with diagnosis as vaginal pH will be increased from acidic to neutral. The Papanicolaou test is not recommended because of poor clinical correlation. First-line treatment is low-dose local vaginal estrogen therapy, which has proven efficacy and safety. Serum estrogen levels are not significantly affected with the exception of creams containing high-dose conjugated equine estrogens. Other options have yet to be approved for use in Canada but show promise.

Conclusion:

GSM is a debilitating and common condition that suffers from barriers to diagnosis and treatment. Current treatments are well tolerated, rewarding, and effective with rapid onset.

Comparison between vaginal royal jelly and vaginal estrogen effects on quality of life and vaginal atrophy in postmenopausal women: a clinical trial study

Objective

This study was conducted to evaluate the therapeutic effects of vaginal royal jelly and vaginal estrogen on quality of life and vaginal atrophy in postmenopausal women.

Methods

This double-blind randomized controlled clinical trial was carried out at gynecology and obstetrics clinics of Hajar Hospital of Shahrekord University of Medical Sciences (Iran) from January 2013 to January 2014. The study was conducted on married postmenopausal women between 50 and 65 years old. Of 120 patients, 30 individuals were excluded based on the exclusion criteria, and 90 women were randomly distributed into three groups of 30 royal jelly vaginal cream 15%, vaginal Premarin, and placebo (lubricant), for three months. At the beginning and the end of the study, quality of life and vaginal cytology assay were evaluated. Data were analyzed by SPSS Version 11.

Results

Vaginal cream of royal jelly is significantly more effective than vaginal cream of Premarin and lubricant in improvement of quality of life in postmenopausal women (p<0.05). Moreover, Pap smear results showed that vaginal atrophy in vaginal Premarin group was lower than the other groups (p<0.001), and there was no significant difference between lubricant and royal jelly groups (p=0.89).

Conclusion

Administration of vaginal royal jelly was effective in quality-of-life improvement of postmenopausal women. Given to the various properties of royal jelly and its effectiveness on quality of life and vaginal atrophy in postmenopausal women, further studies are recommended for using =royal jelly in improving menopausal symptoms.

Clinical trial registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the IRCT code: 2014112220043n1.

Funding

Shahrekord University of Medical Sciences supported this research (project no. 1440).

Iranian postmenopausal women's experiences of treatment of symptomatic vulvovaginal atrophy

OBJECTIVES

Our aim was to explore the experiences of Iranian postmenopausal women who sought medical help for their symptomatic vulvovaginal atrophy (VVA).

METHODS

Five focus group discussions (FGDs) were conducted. Participants had to be postmenopausal; had bothersome symptoms of VVA for which they came to the clinic; had previously sought medical help for their VVA; and had confirmed physical signs of VVA upon examination by a gynecologist.

RESULTS

Twenty-five women, aged 49-60 years participated in the five FGDs. Twenty women said they currently had >1 VVA symptom at presentation to the clinic. Four major themes emerged from the women's narrative stories: (1) negative impact of VVA on women's life, (2) psychological distress associated with VVA, (3) negative impact of VVA on marriage and relationship, (4) inadequate symptom relief from available treatments due to lack of awareness of VVA treatment options. None of the participants reported ongoing treatment of their VVA with local low-dose estrogen. Women further commented that, although local estrogen products were costly, they would like to use them if they were prescribed.

CONCLUSIONS

Considering the negative impact of VVA symptoms on women's lives, health professionals in Iran should be prescribing approved and effective therapies for symptomatic women.

The Impact of Inflammatory and Infectious Diseases of Vulvar on Quality of Life

Objectives

This study aimed to evaluate the effects of vulvar dermatoses (VD) and vulvar infections (VE) on anxiety, depression scores, general, and dermatological quality of life (QOL) of women.

Methods

We conducted a cross-sectional survey on patients diagnosed with VD and VE. All patients were assessed using a sociodemographic form, Skindex-29 scale, World Health Organization QOL (WHOQOL) BREF scale, Hamilton anxiety rating scale (HAM-A), Hamilton depression rating scale (HAM-D).

Results

HAM-A score was significantly higher in the VD group than in the control group. Based on age groups, all subscales of Skindex-29 were found to be higher in women > 50 years. For women with severe pruritus, the symptom subscale was higher in patients with skin involvement and the function and emotion subscales were higher in patients with and emotion subscales were higher in patients with mucosal involvement.

Conclusions

We found that VD was particularly significantly associated with decreased QOL.

Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management

Genitourinary syndrome of menopause, a new term for a condition more renowned as atrophic vaginitis, is a hypoestrogenic condition with external genital, urological, and sexual implications that affects >50% of postmenopausal women. Due to sexual embarrassment and the sensitive nature of discussing symptoms, genitourinary syndrome of menopause is greatly underdiagnosed. The most up-to-date literature pertaining to clinical manifestations, pathophysiology, etiology, evaluation, and management of genitourinary syndrome of menopause is comprehensively reviewed. Early detection and individually tailored pharmacologic (eg, estrogen therapy, selective estrogen receptor modulator, synthetic steroid, oxytocin, and dehydroepiandrosterone) and/or nonpharmacologic (eg, laser therapies, moisturizers and lubricants, homeopathic remedies, and lifestyle modifications) treatment is paramount for not only improving quality of life but also for preventing exacerbation of symptoms in women with this condition.

Clinical update on the use of ospemifene in the treatment of severe symptomatic vulvar and vaginal atrophy

The physiological decrease in vaginal estrogens is accountable for the emergence of vulvar and vaginal atrophy (VVA) and its related symptoms such as vaginal dryness, dyspareunia, vaginal and/or vulvar irritation or itching, and dysuria. The repercussion of these symptoms on quality of life often makes it necessary to initiate treatment. Up until now, the treatments available included vaginal moisturizers and lubricants, local estrogens, and hormonal therapy. However, therapeutic options have now been increased with the approval of 60 mg ospemifene, the first nonhormonal oral treatment with an agonist effect on the vaginal epithelium and an endometrial and breast safety profile which makes it unique. This is the first selective estrogen receptor modulator indicated in women with moderate-to-severe vaginal atrophy not eligible for local estrogen treatment. Considering that "local estrogen noneligible women" are those in whom such treatment cannot be administered either because it is contraindicated or due to skill issues, who are averse to the mode and convenience of vaginal products' administration or to their use on account of potential systemic absorption, or those who demonstrate dissatisfaction in terms of efficacy and safety, it is clear that there is a significant unmet medical need in VVA management. In fact, a great number of women show lack of adherence, dropping out of at least one VVA treatment, including nonhormonal moisturizers and lubricants, which they consider to be ineffective and uncomfortable. If they could choose, many of them may opt for oral treatment. In Phase III studies, ospemifene demonstrated efficacy in vaginal dryness and dyspareunia, regenerating vaginal cells, improving lubrication, and reducing pain during sexual intercourse. Symptoms improved in the first 4 weeks and endured for up to 1 year. Additionally, it demonstrated a good endometrial, cardiovascular system, and breast safety profile.

Female sexual dysfunction (FSD): Prevalence and impact on quality of life (QoL)

Female sexual dysfunction (FSD) and quality of life (QOL) are both multidimensional and have a bidirectional relationship across the reproductive life span and beyond. Methodological difficulties exist in estimating the real prevalence of FSD because it is hard to determine the level of distress associated with sexual symptoms in a large-scale survey. Approximately 40-50% of all women report at least one sexual symptom, and some conditions associated with hormonal changes at menopause, such as vulvovaginal atrophy (VVA) and hypoactive sexual desire disorder (HSDD), have a significant impact on sexual function and QOL. Sexual distress peaks at midlife, declines with age and is strongly partner-related. Many postmenopausal women are still sexually active, especially if they are in a stable partnership. Even though sexual functioning is impaired, a variety of psychosocial factors may maintain sexual satisfaction. That being so, health care providers (HCPs) should proactively address sexual symptoms at midlife and in older women, from a balanced perspective. Adequate counselling should be offered. Women with distressing symptoms may benefit from tailored hormonal and non-hormonal therapies, whereas women without distress related to their sexual experiences should not receive any specific treatment.

Quality of life and sexual function of naturally postmenopausal women on an ultralow-concentration estriol vaginal gel

OBJECTIVE

This study aims to evaluate the sexual function and quality of life (QoL) of naturally postmenopausal women affected by genitourinary syndrome of menopause who were treated with an ultralow-concentration estriol vaginal gel (0.005%).

METHODS

Postmenopausal women with vulvovaginal atrophy symptoms and sexual disorders were enrolled in a case-control study. Women were treated with vaginal gel (containing 50 μg of estriol) daily for 3 weeks and then twice weekly up to 12 weeks. Determination of vaginal maturation index, evaluation of vaginal pH, and assessment of vaginal atrophy symptoms were carried out. QoL, sexual function, and distress were investigated using the Short Form 36, Female Sexual Function Index, and Female Sexual Distress Scale questionnaires. Changes between baseline and week 12 were assessed.

RESULTS

Sixty-eight women were included in the study group, and 42 women were included in the control group. Women on estriol vaginal gel had a significant increase in vaginal maturation index and improvement of vaginal pH compared with baseline (P < 0.05). Mean total Female Sexual Function Index score improved, and Female Sexual Distress Scale score decreased from baseline to follow-up. Results from the Short Form 36 questionnaire showed a significant improvement in the overall index of somatic aspects (P < 0.05). The control group showed no changes from baseline evaluation (P = NS).

CONCLUSIONS

Estriol vaginal gel (0.005%) therapy significantly improves the trophism of the vaginal mucosa and the sexual health and QoL of naturally postmenopausal women. These results confirm that low doses of vaginal estrogen must be considered as the first choice for the initial treatment of postmenopausal genitourinary symptoms.

The effect of microablative fractional CO2 laser on vaginal flora of postmenopausal women

OBJECTIVES

To assess the effect of microablative fractional CO2 laser (MFCO2-Laser) therapy on the vaginal microenvironment of postmenopausal women.

METHODS

Three laser therapies at monthly intervals were applied in postmenopausal women with moderate to severe symptoms of genitourinary syndrome of menopause, pH of vaginal fluid >4.5 and superficial epithelial cells on vaginal smear <5%. Vaginal fluid pH values, fresh wet mount microscopy, Gram stain and aerobic and anaerobic cultures were evaluated at baseline and 1 month after each subsequent therapy. Nugent score and Hay-Ison criteria were used to evaluate vaginal flora.

RESULTS

Fifty-three women (mean age 57.2 ± 5.4 years) participated and completed this study. MFCO2-Laser therapy increased Lactobacillus (p < 0.001) and normal flora (p < 0.001) after the completion of the therapeutic protocol, which decreased vaginal pH from a mean of 5.5 ± 0.8 (initial value) to 4.7 ± 0.5 (p < 0.001). The prevalence of Lactobacillus changed from 30% initially to 79% after the last treatment. Clinical signs and symptoms of bacterial vaginosis, aerobic vaginitis or candidiasis did not appear in any participant.

CONCLUSION

MFCO2-Laser therapy is a promising treatment for improving the vaginal health of postmenopausal women by helping repopulate the vagina with normally existing Lactobacillus species and reconstituting the normal flora to premenopausal status.

Diagnosis and management of symptoms associated with vulvovaginal atrophy: expert opinion on behalf of the Italian VVA study group. Gynecol Endocrinol 2016;32:602-606. [PMID: 27187159 PMCID: PMC5152549 DOI: 10.1080/09513590.2016.1183627]

Vulvovaginal atrophy (VVA) is a chronic disorder that commonly occurs in postmenopausal women, whose symptoms are recognized among the most frequent and bothersome symptoms associated with menopause. The principal therapeutic goal in managing VVA is to relieve symptoms as well as to restore the vaginal environment to a healthy state. However, despite its high prevalence and negative impact on quality of life, VVA is underreported by women, underrecognized by gynecologists, and therefore, undertreated. In the light of the new development of treatment options for VVA, we here provide an updated expert opinion on the management of VVA. In particular, we strongly recommend that HCPs proactively start an open discussion with their postmenopausal patients about urogenital symptoms. Treatment should be started as early as the first symptoms of VVA occur and should be maintained over time, due to the chronicity of the conditions. Many treatment options are now available and therapy should be individualized, taking the woman's preference in consideration.

Genitourinary syndrome of the menopause--dawn of a new era?

Many millions of postmenopausal women continue to suffer in silence from symptoms resulting from estrogen-deficient atrophy of the vulva, vagina and urinary tract whilst the medical profession continues to debate what the condition should be called, how it should be assessed and whether it should be universally treated. It is high time that a unified approach was adopted by all medical societies to reach a consensus on definitions, recognition and management. With the development of the nomenclature for genitourinary syndrome of the menopause (GSM), advances in GSM assessment tools and quality-of-life questionnaires and novel therapeutic interventions, the signs are positive that a new era is finally dawning.

Efficacy, tolerability and safety of a new medical device, Monurelle Biogel(®) vaginal gel, in the treatment of vaginal dryness: a randomized clinical trial in women of reproductive age

OBJECTIVE

To prove the efficacy, tolerability and safety of Monurelle Biogel(®) (ZP-025) vaginal gel, which contains a purified, dialyzed, lyophilized bovine colostrum, in women of reproductive age suffering from vaginal dryness.

DESIGN

Randomized clinical trial (RCT) (Z7213M01).

SETTING

Five University Gynaecological Units.

PATIENTS

Ninety-five subjects were allocated at random to receive either ZP-025 (n=48) for about 23 intermenstrual days (1 or 2 times/daily intra-vaginally) or no treatment (lubricants on demand were allowed).

MAIN OUTCOME MEASURES

Change of Verbal Rating Scale (VRS) total and single score for vaginal symptoms, Vaginal Health Index (VHI) score, Female Sexual Function index (FSFI) and Female Sexual Distress Scale-revised (FSDS-R) scores.

RESULTS

A total number of 85 subjects was evaluable for primary analyses. Symptoms (VRS) of vaginal discomfort improved significantly already after 11 days, as compared to the control arm (p<0.0001). The mean VHI score was also significantly higher in ZP-025 group (p<0.001) at the end of the study. The analysis of covariance with the baseline value as covariate carried out on the FSFI Total Score showed a statistically significant difference in favour of the ZP-025 arm (p<0.032). A shift from presence to absence of sexual distress (≤11 points) was more prominent in the ZP-025 arm [10 subjects (40%) in the ZP-025 arm (p<0.0001) and 6 subjects (21.4%) in the control arm (p=0.01)]. Women reported a compliance rate of 100% for one ZP-025 application/day. Local tolerability of ZP-025 was excellent or good in 82.9% of the subjects.

CONCLUSIONS

The present multicentre RCT supports the use of Monurelle Biogel(®) in women of reproductive age reporting symptoms of vaginal dryness. A positive impact on vaginal health and sexual function was also evident.

Fractional CO2 laser for vulvovaginal atrophy (VVA) dyspareunia relief in breast cancer survivors

PURPOSE

The aim of this study was to evaluate the efficacy of fractional CO2 laser therapy in breast cancer survivors as a therapeutic method for vulvovaginal atrophy (VVA) dyspareunia.

METHODS

50 patients (mean age 53.3 years) underwent fractional microablative CO2 laser treatment for dyspareunia in oncological menopause (mean time of menopause 6.6 years). The Gloria Bachmann's Vaginal Health Index (VHI) score was chosen as system to evaluate the presence of VVA and its improvement after the treatment. Intensity of dyspareunia was evaluated using a visual analog scale (VAS).

RESULTS

Data indicated a significant improvement in VVA dyspareunia (p < 1.86e-22) in breast cancer survivors who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Moreover, VHI scores were significantly higher 30 days post-treatment (T4) (p < 0.0001). 76 % of patients were satisfied or very satisfied with the treatment results. The majority (52 %) of patients were satisfied after a long-term follow-up (mean time 11 months). No adverse events due to fractional CO2 laser treatment occurred.

CONCLUSIONS

The treatment with fractionated CO2 laser appeared to be a feasible and effective treatment for VVA dyspareunia in breast cancer survivors with contraindications to hormonal treatments.

Evaluation of the acceptability of intravaginal prasterone ovule administration using an applicator

The objective of the study is to evaluate the acceptability of the intravaginal administration of ovules/suppositories of DHEA (dehydroepiandrosterone, prasterone) for the treatment of vulvovaginal atrophy (VVA) in women with moderate to severe dyspareunia who were administered daily for 12 weeks intravaginal 0.50% (6.5 mg) DHEA or placebo. There were a total of 373 women in the per-protocol population who responded to the questionnaire for both treatment groups. While it was planned that the applicator would be evaluated as suitable if at least 80% of participants have a global score  ≤ 2 units, 99% and 100% of participants had a score  ≤ 2 units in the placebo and DHEA groups, respectively, for the global score (mean of 5 questions). When asked about like and dislike the technique of drug administration, 284 comments were positive, while 114 women gave no comment. About 92-94% of women indicated that they were very confident to be able use the applicator successfully in the future. The survey shows a high degree of satisfaction and of confidence to use the applicator successfully in the future.

Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey

Objectives The aim of the European REVIVE survey was to achieve a better understanding of vulvovaginal atrophy (VVA), a chronic and progressive condition after menopause. We investigated perceptions, experiences and needs in terms of sexual and vaginal health in a sample of European postmenopausal women.

Methods An online internet based survey was conducted in Italy, Germany, Spain and the UK with a total surveyed sample of 3768 postmenopausal women (age: 45–75 years).

Results The most common VVA symptom was vaginal dryness (70%). VVA has a significant impact on the ability to be intimate (62%), to enjoy sexual intercourse (72%) and to feel sexual spontaneity (66%). Postmenopausal women with VVA are sexually active (51%), but their sexual drive is reduced. Health-care professionals (HCPs) have discussed VVA with postmenopausal women (62%), but they initiated the conversation only in 10% of the cases. The most common treatments for VVA are over-the-counter, non-hormonal, local vaginal products. Thirty-two per cent of postmenopausal women were naïve to any kind of treatment, whereas discussion with the HCP was relevant to be on current treatment (60% of postmenopausal women that discussed VVA with a HCP vs. 23% who did not). The top reasons for poor compliance with vaginal treatments were: not bothersome enough symptoms (18%); vaginal changes not therapeutically reversed (18%); relief from VVA symptoms (17%). Approximately 45% were satisfied with treatment. The most frequent disliked aspects of treatment were the route of administration or the messiness. The fear of hormones was common in postmenopausal women using vaginal prescription products.

Conclusions The European REVIVE survey confirmed that VVA symptoms are frequent in postmenopausal women and demonstrates a significant impact on quality of life and sexual life. However, the condition is still under-diagnosed and under-treated, with a high rate of dissatisfaction for actual available treatments in the four European countries surveyed. The discussion of symptoms with HCPs seems the most critical factor for diagnosis and treatment of VVA.

Effect of ospemifene on moderate or severe symptoms of vulvar and vaginal atrophy

Objectives To determine whether assessment of all moderate-to-severe symptoms at baseline gives a more accurate evaluation of the treatment effect of ospemifene in vulvovaginal atrophy (VVA) than the most bothersome symptom (MBS) approach.

Methods Data were pooled from two pivotal phase-III clinical trials evaluating the efficacy and safety of oral ospemifene 60 mg/day for the treatment of symptoms of VVA (n = 1463 subjects). Symptoms of vaginal dryness, dyspareunia, and vaginal and/or vulvar irritation/itching reported as moderate or severe at baseline were evaluated. Clinically relevant differences between ospemifene and placebo were analyzed using a four-point severity scoring system and presented as improvement, substantial improvement, or relief.

Results Subjects in these studies reported statistically significant improvement, substantial improvement, and relief for vaginal dryness (p < 0.00001), dyspareunia (p < 0.001) and statistically significant improvement and relief for vaginal and/or vulvar irritation/itching (p < 0.01) from baseline to week 12 with ospemifene compared with placebo. A similar trend was observed for women who reported substantial improvement of vaginal and/or vulvar irritation/itching.

Conclusions For drug registration purposes, the use of the MBS model is appealing because of its simplicity and ease of scientific validation. However, the MBS model may underestimate the total magnitude of the clinical benefit of ospemifene treatment for symptomatic women suffering from VVA.

Serum levels of sex steroids and metabolites following 12 weeks of intravaginal 0.50% DHEA administration

The objective of the present phase III, placebo-controlled, double-blind, prospective and randomized study was to confirm the efficacy of daily intravaginal administration of 0.50% dehydroepiandrosterone (DHEA; prasterone) ovules for 12 weeks on moderate to severe dyspareunia (or pain at sexual activity) as most bothersome symptom of vulvovaginal atrophy (VVA) while having serum steroid concentrations within normal postmenopausal values. To this end, serum levels of DHEA, DHEA-sulfate (DHEA-S), Androst-5-ene-diol-3β, 17β-diol (5-diol), testosterone, dihydrotestosterone (DHT), androstenedione (4-dione), estrone (E1), estradiol (E2), estrone sulfate (E1-S), androsterone glucuronide (ADT-G), and androstane-3α, 17β-diol 17-glucuronide (3α-diol-17G) were measured by validated liquid chromatography-tandem mass spectrometry (LC-MS/MS). In agreement with the mechanisms of intracrinology, all serum sex steroids and metabolites concentrations after 12 weeks of daily intravaginal administration of 0.50% DHEA remain well within the limits of normal postmenopausal women. More specifically, the 12-week serum E2 concentration was measured at 22% below the average normal postmenopausal value (3.26 versus 4.17 pg/ml), thus eliminating any fear of E2 exposure outside the vagina. In addition, serum E1-S, a particularly reliable indicator of global estrogenic activity, shows serum levels practically superimposable to the value observed in normal postmenopausal women (219 versus 220 pg/ml). Similarly, serum ADT-G, the major metabolite of androgens, remains within normal postmenopausal values. The present data confirm the intracellular transformation of DHEA in the vagina resulting in local efficacy without any systemic exposure to sex steroids, observations which are in agreement with the physiological mechanisms of menopause.