Recommendations for the management of postmenopausal vaginal atrophy

Menopause and Sexuality

Sexuality is an important component in the lives of menopausal women. Despite the importance of sexual function in menopausal women, sexual dysfunction increases with age. Age-related decline in sexual function may significantly reduce quality of life, making recognition of sexual dysfunction by physicians important for getting menopausal women effective care. Sexual dysfunction can result from multiple etiologies including psychosocial factors, medication side effects, vulvovaginal atrophy, chronic illness, or hypoactive sexual desire disorder. Discovering the etiology and identifying modifiable factors of the sexual function will help define appropriate treatment.

Menopausal Hormone Therapy: Current Considerations

Menopausal hormone therapy (MHT) is the most effective treatment for vasomotor and vaginal symptoms. Today, symptomatic women younger than 60 years of age or less than 10 years since onset of menopause yield the greatest benefit of MHT with the lowest risks when compared with older women remote from menopause. Careful assessment before initiating therapy includes severity of bothersome symptoms, treatment preferences, medical history, presence of contraindications to MHT, and personal risk of cardiovascular disease and breast cancer. Considerations of type of MHT, dosing, and route of administration, and recommendations regarding duration of therapy are discussed.

Menopause and Cancers

Cancer is a disease of aging, and therefore is more prevalent after menopause. Menopausal symptoms resulting from cancer treatments are an important survivorship issue in cancer care. This article reviews the preventive strategies, utilization of health resources, and management of menopausal symptoms after cancer treatment. Preventive screening as informed by genetic and lifestyle risk, and lifestyle modification, may mitigate the risk of cancer and cancer mortality. Despite potential benefits to quality of life, hormone replacement is rarely prescribed to survivors of gynecologic malignancies. Special considerations are needed for the treatment and supportive care of menopausal symptoms in cancer survivors.

The Recent Review of the Genitourinary Syndrome of Menopause

The genitourinary syndrome of menopause (GSM) is a new term that describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function, but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections). The terms vulvovaginal atrophy and atrophic vaginitis, which were generally used until recently, had a limitation because they did not cover the full spectrum of symptoms and did not imply that the symptoms are related to a decreased estrogen level in menopause. Since the GSM may have a profound negative impact on the quality of life of postmenopausal women, women should be made aware of these problems and treated with an appropriate effective therapy. Thus, in this review we introduce new terminology and discuss the importance of comprehension of GSM and the necessity of active treatment of this syndrome in postmenopausal women.

Assessment of Introital Lubrication

Vaginal vasocongestion and lubrication serve to prepare the vaginal lumen for sexual activity. Lubrication is important for sexual functioning and difficulties with lubrication are one of the most commonly reported symptoms of sexual dysfunction. Few studies have empirically examined how vasocongestion and lubrication relate to one another and there are currently no well-established measures of lubrication. In this study, we designed and tested a simple method to assess lubrication at the vaginal introitus in 19 healthy women, using litmus test strips. We examined the relationship between lubrication and vaginal vasocongestion (measured with a photoplethysmograph) when elicited by audiovisual sexual stimuli (male-female sexual interactions). Lubrication was elicited by the sexual stimuli and was strongly correlated with reports of sexual arousal. Unexpectedly, lubrication was not correlated with vasocongestion, even though the latter was also elicited by the sexual stimuli. We discuss the implications of these findings for informing our understanding of the female sexual response and the potential clinical and scientific utility of this new measure.

Effect of ultra-low-dose estriol and lactobacilli vaginal tablets (Gynoflor®) on inflammatory and infectious markers of the vaginal ecosystem in postmenopausal women with breast cancer on aromatase inhibitors

This study was a detailed microscopic analysis of the changes of vaginal microflora characteristics after application of 0.03 mg estriol-lactobacilli combination on the vaginal ecosystem in postmenopausal breast cancer (BC) survivors on aromatase inhibitors (AI) with severe atrophic vaginitis. A total of 16 BC women on AI applied daily one vaginal tablet of Gynoflor® for 28 days followed by a maintenance therapy of three tablets weekly for 8 weeks. During four follow up visits a smear from the upper lateral vaginal wall was analysed by phase contrast microscopy at 400 times magnification in order to classify the lactobacillary grades(LBG), bacterial vaginosis (BV), aerobic vaginitis (AV), vulvovaginal candidosis (VVC), proportional number of leukocytes and evidence of parabasal cells and epitheliolysis. LBG improved from 81 % LBG-III at entry to 88 % LBG-I&IIa after 2 weeks of initial therapy, which further improved upon follow up (p < 0.001). Whereas BV was a rare event, AV was frequent and substantially improved during treatment (p < 0.01). While at entry most patients had moderate or severe AV, after maintenance therapy no patient except one had AV. The number of leukocytes dropped dramatically from a score of 1.78 ± 0.70 to 1.06 ± 0.25 which was consistent till the end of the study (p < 0.01). Parabasal cells dropped from a score of 3.4 ± 0.64 at entry to 1.3 ± 0.60 at the final visit (p_trend < 0.01). Starting from a low rate of Candida colonisation of 2/14 (14 %), a sudden rise to 7/16 (44 %) occurred after 2 weeks, to return back to base levels at susequent visits. The vaginal use of ultra-low dose estriol and lactobacilli results in rapid and enduring improvement of all markers of the vaginal microflora and epithelial vaginal cell quality in women with breast cancer on AI with dyspareunia. Candida may develop soon after its use, but rapidly disappears again upon their prolonged use. Due to its excellent safety profiles and clinical efficacy we recommend this product as first choice in women on AI with severe dyspareunia.

Oestrogen replacement in postmenopausal women

Menopausal symptoms can disrupt a woman's personal and social life. Vasomotor symptoms (hot flushes and night sweats) are the most common symptoms and can be treated very effectively with oestrogen-based hormone therapy. The decision to use oestrogen (often simply termed hormone therapy or hormone replacement therapy or HT) therapy involves balancing the potential benefits against the potential risks. Most agree that short-term oestrogen therapy, using the lowest effective dose, is a reasonable option for recently menopausal women with moderate-to-severe symptoms who are in good cardiovascular health (Martin and Manson. 2008. J. Clin. Endocrinol. Metab. 93, 4567-75). Whilst effective and safe in most instances, HT is not suitable for all women or for all menopause-related symptoms when alternatives are available. The role of HRT in chronic disease prevention is also discussed.

Genitourinary Syndrome of Menopause in Breast Cancer Survivors: Are We Facing New and Safe Hopes?

Breast cancer survivors (BCSs) often suffer from menopausal symptoms induced by systemic treatments, with a consequent negative effect on quality of life. Since the introduction of aromatase inhibitors as the standard therapy for hormone-dependent tumors, genitourinary syndrome of menopause (GSM) has become a main problem for BCSs. This new terminology refers to the wide range of vaginal and urinary symptoms related to menopause, which can be relieved by estrogen therapy. Unfortunately, systemic hormone therapy is contraindicated for BCSs and also vaginal estrogens at standard dosage might influence the risk of recurrence because they cause a significant increase of circulating estrogens. Nonhormonal vaginal moisturizers or lubricants are the first choice for BCSs but only have limited and short-term efficacy. New strategies of management of GSM are now available, including: (1) low-dose or ultra low-dose vaginal estrogens; (2) oral selective estrogen receptor modulators (ospemifene); (3) androgen therapy; (4) physical treatment with vaginal laser; and (5) psychosocial interventions. In this review we discuss and analyze these different options.

Vaginal oestrogen for overactive bladder in post-menopausal women

This article asks the question 'Should nurses recommend vaginal oestrogen for overactive bladder in post-menopausal women?' The article will review the evidence for use of vaginal oestrogen and consider the potential side-effects and risks. The main finding is that vaginal oestrogen is effective for treatment of overactive bladder in post-menopausal women with vaginal atrophy. However, vaginal atrophy is undertreated. This article identifies some of the barriers that may prevent diagnosis and treatment, and suggests changes in practice. Nurses should take the initiative and ask post-menopausal women about symptoms. Nurses should be trained to examine women, diagnose vaginal atrophy and discuss treatment.

Characteristics of post-menopausal women with genitourinary syndrome of menopause: Implications for vulvovaginal atrophy diagnosis and treatment selection

BACKGROUND

Vulvovaginal atrophy (VVA), also known as genitourinary syndrome of menopause, exerts a negative impact on the sexuality, health and quality of life of post-menopausal women. A better understanding of post-menopausal women's profiles as defined by their attitude and behaviours in relation to their VVA symptoms may improve public health policies and will allow appropriate targeting of public health campaigns. These improvements may help women of middle and advanced age recover and maintain their quality of life. In this study, we analysed the attitudes of post-menopausal women, aged 45-74 years, with VVA symptoms from five European countries, with the aim of identifying profile markers to improve healthcare strategies.

METHODS

Two consecutive cross-sectional studies were conducted in five European countries (the UK, France, Spain, Germany and Italy). An initial exploratory study (n=69) was based on interviews and then an analytical study (n=749) was based on online surveys to validate women's profiles by means of a multi-level approach.

RESULTS

We identified eight profiles: self-treater, pragmatic, vivacious, reserved, silent sufferer, expressive, stoic and sad. The percentage distribution varied among the countries. The 'pragmatic', 'vivacious' and 'expressive' women were the most proactive, talkative and open with their healthcare professional, whereas women with the 'reserved' and 'stoic' profiles showed less interest in searching for information about their VVA symptoms, either from their healthcare professional or from other sources.

CONCLUSIONS

The attitudes and behaviours of post-menopausal women in relation to their VVA allow for the clear definition of a series of profiles with varying representation across countries. This study reveals the importance of identifying post-menopausal women's profiles to develop interventions to help them overcome barriers to the diagnosis, management and treatment of VVA.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

BACKGROUND

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The 2 societies cosponsored a terminology consensus conference, which was held in May 2013.

RESULTS AND CONCLUSIONS

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause (GSM)--in 2014.

Intravaginally applied oxytocin improves post-menopausal vaginal atrophy

Objective

To explore the efficacy of local oxytocin for the treatment of post-menopausal vaginal atrophy.

Design

Double-blinded randomised controlled trial.

Setting

Healthy post-menopausal women in Stockholm, Sweden.

Participants

Sixty four post-menopausal women between February and June 2012 at the Karolinska University Hospital Huddinge/Sweden.

Main outcome measures

The efficacy of oxytocin for treatment of vaginal atrophy after seven weeks and cytological evaluation.

Results

The percentage of superficial cells in the vaginal smears and the maturation values were significantly increased after seven weeks of treatment with vagitocin 400 IU (p = 0.0288 and p = 0.0002, respectively). The vaginal pH decreased significantly after seven weeks of treatment with vagitocin 100 IU (p = 0.02). The scores of vaginal atrophy, according to the histological evaluation, were significantly reduced after administration of vagitocin 100 IU (p = 0.03). The thickness of the endometrium did not differ between the treatment and placebo groups after seven weeks of treatment. The symptom experienced as the most bothersome was significantly reduced after seven weeks of treatment in the women receiving vagitocin 400 IU compared to women in the placebo group (p = 0.0089).

Conclusions

Treatment with intravaginally applied oxytocin could be an alternative to local estrogen treatment in women with post-menopausal vaginal atrophy.

Atrophic vaginitis in breast cancer survivors: a difficult survivorship issue

Management of breast cancer includes systematic therapies including chemotherapy and endocrine therapy can lead to a variety of symptoms that can impair the quality of life of many breast cancer survivors. Atrophic vaginitis, caused by decreased levels of circulating estrogen to urinary and vaginal receptors, is commonly experienced by this group. Chemotherapy induced ovarian failure and endocrine therapies including aromatase inhibitors and selective estrogen receptor modulators can trigger the onset of atrophic vaginitis or exacerbate existing symptoms. Symptoms of atrophic vaginitis include vaginal dryness, dyspareunia, and irritation of genital skin, pruritus, burning, vaginal discharge, and soreness. The diagnosis of atrophic vaginitis is confirmed through patient-reported symptoms and gynecological examination of external structures, introitus, and vaginal mucosa. Lifestyle modifications can be helpful but are usually insufficient to significantly improve symptoms. Non-hormonal vaginal therapies may provide additional relief by increasing vaginal moisture and fluid. Systemic estrogen therapy is contraindicated in breast cancer survivors. Continued investigations of various treatments for atrophic vaginitis are necessary. Local estrogen-based therapies, DHEA, testosterone, and pH-balanced gels continue to be evaluated in ongoing studies. Definitive results are needed pertaining to the safety of topical estrogens in breast cancer survivors.

Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy

OBJECTIVE

The vaginal microbiota helps protect the female genital tract from disease. We sought to describe the composition of the vaginal microbiota in premenopausal, perimenopausal, and postmenopausal women and to explore the association between the microbiota and vulvovaginal atrophy (VVA).

METHODS

Eighty-seven women (aged 35-60 y) were classified as premenopausal (n = 30), perimenopausal (n = 29), or postmenopausal (n = 28) according to Stages of Reproductive Aging Workshop guidelines. Midvaginal bacterial community composition was characterized by 16S ribosomal RNA gene analysis.

RESULTS

Bacterial communities clustered into six community state types (CSTs), of which four were dominated by Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus iners, or Lactobacillus jensenii, and two (CST IV-A and CST IV-B) had low relative abundance of Lactobacillus. CST IV-A was characterized by Streptococcus and Prevotella, whereas CST IV-B was characterized by Atopobium. There were significant associations between menopause stage and CST (P = 0.004) and between VVA and CST (P = 0.002). Perimenopausal women were more likely to be classified as CST IV-A or L. gasseri CST, whereas postmenopausal women were often classified as CST IV-A. CSTs dominated by L. crispatus and L. iners were more prevalent in premenopausal women. Nineteen participants had signs of mild or moderate VVA. Compared with women with no VVA, the vaginal microbiota of women with mild or moderate atrophy had 25-fold greater odds of being classified as CST IV-A versus L. crispatus CST (adjusted odds ratio, 25.89; 95% credible interval, 2.98-406.79).

CONCLUSIONS

A distinct bacterial community state (CST IV-A) with a low relative abundance of Lactobacillus is associated with VVA. Future studies recruiting a larger number of women are needed to replicate the findings. This study provides an impetus for future longitudinal studies designed to manage, modulate, and restore vaginal microbiota homeostasis, which would provide stronger evidence for a causal relationship with VVA and ultimately improve the treatment and prevention of atrophic vaginitis in menopause.

Vaginal epithelium and microflora characteristics in women with premature ovarian failure under hormone therapy compared to healthy women

PURPOSE

To evaluate some microbiological aspects of the vaginal flora and the vaginal trophism of women with premature ovarian failure (POF) in use of oral hormone therapy.

METHODS

A cross-sectional study with 36 women with POF under the age of 40 years using oral hormonal therapy. They were age matched with 36 women with normal gonadal function (control group). The characteristics of the vaginal epithelium were assessed through the hormonal vaginal cytology, vaginal pH measurement and vaginal health index to identify vaginal disturbances. Vaginal microflora was evaluated by the amine test, bacterioscopy (Nugent score) and culture for fungi to identify vaginal abnormal microflora and fungi infections.

RESULTS

Despite the fact that there were no statistical significant differences related to the cytological aspects and pH measurements, it was found that the vaginal health index was highly superior in the control group than in the POF group (23.4 ± 1.8 vs 20.8 ± 3.5), p < 0.0001 despite both groups had trophic scores. There were no statistical significance differences regarding to vaginal microflora types and fungi infection.

CONCLUSION

Oral hormone therapy for young women with POF seems to be good enough to reestablish the epithelium cells, vaginal pH and microflora.

Dehydroepiandrosterone intra vaginal administration for the management of postmenopausal vulvovaginal atrophy

The effects of intravaginal administration of dehydroepiandrosterone (DHEA) for the management of symptomatic vulvovaginal atrophy are reviewed. A literature search related to vulvovaginal atrophy, vaginal atrophy, atrophic vaginitis, estrogen, dehydroepiandrosterone, vulvar itching, burning, dryness, dyspareunia, and libido was performed. Relevant articles addressing the incidence, management, and outcome of DHEA therapy were identified and used for this Expert Opinion. DHEA compared to a placebo is an effective treatment improving symptoms of vaginal atrophy: dyspareunia, burning, itching, and dryness. Objective parameters of vaginal atrophy, specifically pH, vaginal maturation index (VMI), and investigator-evaluated changes in the vagina: moisture, epithelia integrity and color were improved compared to baseline and placebo. There were significant improvements in libido and dyspareunia with the intravaginal use of DHEA that contribute to improved quality of life for postmenopausal women. Dehydroepiandrosterone administered intravaginally on a daily basis is an effective treatment for symptoms, and signs of vulvovaginal atrophy along with libido in postmenopausal women. This article is part of a Special Issue entitled 'Essential role of DHEA'.

Newly developed vaginal atrophy symptoms II and vaginal pH: a better correlation in vaginal atrophy?

OBJECTIVES

The primary objective of this study was to evaluate the correlation among symptoms, signs, and the number of lactobacilli in postmenopausal vaginal atrophy. The secondary objective was to develop a new parameter to improve the correlation.

STUDY DESIGN

A cross-sectional descriptive study.

METHODS

Naturally postmenopausal women aged 45-70 years with at least one clinical symptom of vaginal atrophy of moderate to severe intensity were included in this study. All of the objective parameters (vaginal atrophy score, vaginal pH, the number of lactobacilli, vaginal maturation index, and vaginal maturation value) were evaluated and correlated with vaginal atrophy symptoms. A new parameter of vaginal atrophy, vaginal atrophy symptoms II, was developed and consists of the two most bothersome symptoms (vaginal dryness and dyspareunia). Vaginal atrophy symptoms II was analyzed for correlation with the objective parameters.

RESULTS

A total of 132 naturally postmenopausal women were recruited for analysis. Vaginal pH was the only objective parameter found to have a weak correlation with vaginal atrophy symptoms (r = 0.273, p = 0.002). The newly developed vaginal atrophy symptoms II parameter showed moderate correlation with vaginal pH (r = 0.356, p < 0.001) and a weak correlation with the vaginal atrophy score (r = 0.230, p < 0.001). History of sexual intercourse within 3 months was associated with a better correlation between vaginal atrophy symptoms and the objective parameters.

CONCLUSION

Vaginal pH was significantly correlated with vaginal atrophy symptoms. The newly developed vaginal atrophy symptoms II was associated with a better correlation. The vaginal atrophy symptoms II and vaginal pH may be better tools for clinical evaluation and future study of the vaginal ecosystem.

Vulvo-vaginal atrophy: a new treatment modality using thermo-ablative fractional CO2 laser

OBJECTIVE

To evaluate the efficacy and feasibility of thermo-ablative fractional CO2 laser for the treatment of symptoms related to vulvo-vaginal atrophy (VVA) in post-menopausal women.

METHODS

From April 2013 to December 2013, post-menopausal patients who complained of one or more VVA-related symptoms and who underwent vaginal treatment with fractional CO2 laser were enrolled in the study. At baseline (T0) and 30 days post-treatment (T1), vaginal status of the women was evaluated using the Vaginal Health Index (VHI), and subjective intensity of VVA symptoms was evaluated using a visual analog scale (VAS). At T1, treatment satisfaction was evaluated using a 5-point Likert scale.

RESULTS

During the study period, a total of 48 patients were enrolled. Data indicated a significant improvement in VVA symptoms (vaginal dryness, burning, itching and dyspareunia) (P<0.0001) in patients who had undergone 3 sessions of vaginal fractional CO2 laser treatment. Moreover, VHI scores were significantly higher at T1 (P<0.0001). Overall, 91.7% of patients were satisfied or very satisfied with the procedure and experienced considerable improvement in quality of life (QoL). No adverse events due to fractional CO2 laser treatment occurred.

CONCLUSION

Thermo-ablative fractional CO2 laser could be a safe, effective and feasible option for the treatment of VVA symptoms in post-menopausal women.

Sexual function after fractional microablative CO₂ laser in women with vulvovaginal atrophy

OBJECTIVE

To investigate the effects of fractional microablative CO2 laser on sexual function and overall satisfaction with sexual life in postmenopausal women with vulvovaginal atrophy (VVA).

METHOD

This prospective study included 77 postmenopausal women (mean age 60.6 ± 6.2 years) treated for VVA symptoms with the fractional microablative CO2 laser system (SmartXide(2) V(2)LR, Monalisa Touch, DEKA, Florence, Italy). Sexual function and quality of life were evaluated with the Female Sexual Function Index (FSFI) and the Short Form 12 (SF-12), respectively, both at baseline and at 12-week follow-up. A 10-mm visual analog scale was used to measure the overall satisfaction with sexual life and the intensity of VVA symptoms (vaginal burning, vaginal itching, vaginal dryness, dyspareunia and dysuria) before and after the study period.

RESULTS

We observed a significant improvement in the total score and the scores in each specific domain of the FSFI at 12-week follow-up compared to baseline (p < 0.001). After concluding the laser treatment, the overall satisfaction with sexual life significantly improved (p < 0.001). Seventeen (85%) out of 20 (26%) women, not sexually active because of VVA severity at baseline, regained a normal sexual life at the 12-week follow-up. Finally, we also found a significant improvement in each VVA symptom (p < 0.001) and in quality-of-life evaluation, both for the scores in the physical (p = 0.013) and mental (p = 0.002) domains.

CONCLUSIONS

Fractional microablative CO2 laser treatment is associated with a significant improvement of sexual function and satisfaction with sexual life in postmenopausal women with VVA symptoms.

The clinical relevance of the effect of ospemifene on symptoms of vulvar and vaginal atrophy

Objectives

To explore clinically relevant differences in severity of vulvar and vaginal atrophy (VVA) in postmenopausal women treated with ospemifene compared with placebo.

Methods

Analysis of two multicenter, randomized, double-blind, 12-week phase-III studies in postmenopausal women (40–80 years, with VVA, treated with ospemifene 60 mg/day or placebo (Study 310 and Study 821)). Severity of vaginal dryness and dyspareunia were evaluated using a four-point scoring system and clinically relevant differences between ospemifene and placebo were analyzed and are presented as improvement (reduction in ≥ 1 unit on four-point scoring system), substantial improvement (reduction in 2–3 units on four-point scoring system) and relief (severity score of mild/none after 12 weeks).

Results

In Study 310, significantly more women with a most bothersome symptom of dyspareunia had improvement (68.3% vs. 54.1%; p = 0.0255) or relief (57.5% vs. 41.8%; p = 0.0205) in the severity of dyspareunia from baseline to week 12 with ospemifene compared with placebo. For those with a most bothersome symptom of vaginal dryness, significantly more experienced improvement (74.6% vs. 57.7%; p = 0.0101), substantial improvement (42.4% vs. 26.9%; p = 0.0172) and relief (66.1% vs. 49.0%; p = 0.0140) of vaginal dryness from baseline to week 12 with ospemifene compared with placebo. Proportions of women with improvement/substantial improvement/relief of symptoms of vaginal dryness or dyspareunia were similar in Study 821. Clinically relevant differences were noticeable by week 4.

Conclusions

Treatment with ospemifene was consistently associated with greater improvement, substantial improvement or relief in the severity of the most bothersome symptoms of vaginal dryness or dyspareunia compared with placebo.

Expression of the estrogen receptors and steroidogenic enzymes involved in estradiol formation in the monkey vagina

OBJECTIVE

Estrogens are well recognized to have beneficial effects on vulvovaginal atrophy because of menopause. The distribution of estrogen receptors and enzymes responsible for estradiol (E2) formation within the vagina may provide insight into how dehydroepiandrosterone, a precursor of both estrogens and androgens, improves vulvovaginal atrophy.

STUDY DESIGN

The purpose of the study was to determine where the steroidogenic enzymes responsible for E2 formation as well as estrogen receptors are localized in vaginal specimens collected from cynomolgus monkeys (Macaca fascicularis), the closest model to the human. HSD3B1, HSD17B1, HSD17B5, HSD17B12, aromatase (CYP19A1), estrogen receptor (ER)-α, and ER-β were measured or localized by quantitative real-time polymerase chain reaction, immunohistochemistry, and immunofluorescence. Estrogens were quantified by liquid chromatography/tandem mass spectrometry.

RESULTS

All steroidogenic enzymes and estrogen receptors are localized mainly in the superficial layer of the stratified squamous epithelium, blood vessel walls, and muscle fibers of the vagina. Immunolabeling of HSD17B5 and HSD17B12 shows that these enzymes are uniformly distributed from the basal membrane to the superficial keratinized cells, whereas HSD3B1 and aromatase are particularly localized in the outer (external) portion of the epithelial layer. ER-α and ER-β are also distributed within the vaginal epithelium, with expression especially elevated at the basal membrane level.

CONCLUSION

The enzymes responsible for E2 formation as well as ERs are expressed mainly in the superficial layer of the stratified epithelium as well as the muscle layer of the vagina. The present data provide morphologic and biochemical support for the role of local dehydroepiandrosterone transformation into estrogens in regulating epithelial cell maturation, pH, fluid secretion, smooth muscle activity, and blood flow regulation in the primate vagina.

Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women

Introduction

Vaginal atrophy, which may affect up to 45% of postmenopausal women, is often associated with one or more urinary symptoms, including urgency, increased frequency, nocturia, dysuria, incontinence, and recurrent urinary tract infection.

Aims

To provide an overview of the current literature regarding cellular and clinical aspects of vaginal atrophy and response to treatment with local vaginal estrogen therapy.

Methods

PubMed searches through February 2012 were conducted using the terms “vaginal atrophy,” “atrophic vaginitis,” and “vulvovaginal atrophy.” Expert opinion was based on review of the relevant scientific and medical literature.

Main Outcome Measure

Genitourinary symptoms and treatment of vaginal atrophy from peer-reviewed published literature.

Results

Typically, a diagnosis of vaginal atrophy is made based on patient-reported symptoms, including genitourinary symptoms, and an examination that reveals signs of the disorder; however, many women are hesitant to report vaginal-related symptoms, primarily because of embarrassment.

Conclusions

Physicians in various disciplines are encouraged to initiate open discussions about vulvovaginal health with postmenopausal women, including recommended treatment options. Goldstein I, Dicks B, Kim NN, and Hartzell R. Multidisciplinary overview of vaginal atrophy and associated genitourinary symptoms in postmenopausal women. Sex Med 2013;1:44–53.

Ospemifene: a novel selective estrogen receptor modulator for treatment of dyspareunia

Ospemifene is a novel, oral selective estrogen receptor modulator that has been approved in the USA for treatment of dyspareunia. The decline in estrogen during menopause creates vulvovaginal changes that can cause symptoms that adversely impact women psychosexually. Many women are reluctant to discuss painful sex and providers must proactively inquire about sexuality issues. Ospemifene has been shown to reverse changes associated with vulvovaginal atrophy and relieve symptoms of dyspareunia. Safety studies of treatment up to 52 weeks have shown ospemifene to be safe with no impact on endometrial hyperplasia/carcinoma, venous thrombotic events or pelvic organ prolapse. Further studies are needed to evaluate its role in bone and breast health.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and The North American Menopause Society

BACKGROUND

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The two societies cosponsored a terminology consensus conference, which was held in May 2013.

RESULTS AND CONCLUSION

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology - genitourinary syndrome of menopause (GSM) - in 2014.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

INTRODUCTION

The terminology for the genitourinary tract symptoms related to menopause was vulvovaginal atrophy, which does not accurately describe the symptoms nor is a term that resonates well with patients.

AIM

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The two societies cosponsored a terminology consensus conference, which was held in May 2013.

MAIN OUTCOME MEASURE

The development of a new terminology that more accurately described the genitourinary tract symptoms related to menopause.

RESULTS

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra, and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis.

CONCLUSION

The term GSM was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause--in 2014.

Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society

BACKGROUND

In 2012, the Board of Directors of the International Society for the Study of Women's Sexual Health (ISSWSH) and the Board of Trustees of The North American Menopause Society (NAMS) acknowledged the need to review current terminology associated with genitourinary tract symptoms related to menopause.

METHODS

The 2 societies cosponsored a terminology consensus conference, which was held in May 2013.

RESULTS AND CONCLUSION

Members of the consensus conference agreed that the term genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing, and publicly acceptable term than vulvovaginal atrophy. GSM is defined as a collection of symptoms and signs associated with a decrease in estrogen and other sex steroids involving changes to the labia majora/minora, clitoris, vestibule/introitus, vagina, urethra and bladder. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Women may present with some or all of the signs and symptoms, which must be bothersome and should not be better accounted for by another diagnosis. The term was presented and discussed at the annual meeting of each society. The respective Boards of NAMS and ISSWSH formally endorsed the new terminology--genitourinary syndrome of menopause (GSM)--in 2014.

Menopausal hormone therapy use in 17 European countries during the last decade

INTRODUCTION

The first 'Women's Health Initiative' (WHI) randomised controlled trial assessed use of continuous combined menopausal hormone therapy (cc-MHT). It was prematurely stopped because of an increased invasive breast cancer (BC), coronary heart disease (CHD), stroke and pulmonary embolism risk. Consequently, scientific societies recommended use of MHT at the lowest effective dose for the shortest duration. As a result, a sharp decline in MHT use occurred worldwide.

AIM

To report in a uniform way the change in MHT use in European countries. To evaluate whether the variability of the MHT changes were related to some medical indicators.

MATERIALS AND METHODS

IMS Health provided MHT sales data for the years 2002 till 2010 for 17 countries. We tested several hypotheses to explain the heterogeneity of MHT use changes.

RESULTS AND DISCUSSION

In 2002, the estimated MHT rate in women 45-69 years old varied considerably between countries ranging from less than 5% to more than 25%. In all countries a profound decrease occurred between 2002 and 2010, ranging from 50% to 77%. By the end of 2010, the MHT uptake was lower than 10% in all countries except in Finland. MHT use change was not correlated to MHT use and prevailing BC incidence at baseline, nor to the number of gynaecologists per 100,000 women or to the level of information about MHT.

CONCLUSION

The global MHT use experienced a sharp decrease in all the analysed countries, although some variability exists. The decrease was unrelated to the assessed parameters.

Management of Vaginal Atrophy: Implications from the REVIVE Survey

Vulvar and vaginal atrophy (VVA) is a chronic and progressive medical condition common in postmenopausal women. Symptoms of VVA such as dyspareunia, vaginal dryness, irritation, and itching can negatively impact sexual function and quality of life. The REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and recorded attitudes about interactions with healthcare providers (HCPs) and available treatment options for VVA. The REVIVE survey identified unmet needs of women with VVA symptoms such as poor understanding of the condition, poor communication with HCPs despite the presence of vaginal symptoms, and concerns about the safety, convenience, and efficacy of available VVA treatments. HCPs can address these unmet needs by proactively identifying patients with VVA and educating them about the condition as well as discussing treatment preferences and available therapies for VVA.

A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study

OBJECTIVE

This pilot study aimed to assess the efficacy and feasibility of fractional CO2 laser in the treatment of vulvovaginal atrophy (VVA) in postmenopausal women.

METHODS

VVA symptoms were assessed before and after three applications of laser over 12 weeks in 50 women (age 59.6 ± 5.8 years) dissatisfied with previous local estrogen therapies. Subjective (visual analog scale) and objective (Vaginal Health Index Score, VHIS) measures were used during the study period to assess VVA. Quality of life was measured by using the SF-12. A subjective scale to evaluate the degree of pain related to the laser application and the degree of difficulty to perform the laser procedure was used.

RESULTS

Fractional CO2 laser treatment was effective to improve VVA symptoms (vaginal dryness, vaginal burning, vaginal itching, dyspareunia, dysuria; p < 0.001) at 12-week follow-up, as well as the VHIS (13.1 ± 2.5 at baseline vs. 23.1 ± 1.9; p < 0.001). Both physical and mental scores of quality of life were significantly improved in comparison with baseline (p < 0.001). Satisfaction with the laser procedure was reported by 42 women (84%) and a minimal discomfort was experienced at the first laser application, mainly because of the insertion and the movements of the probe. Finally, the technique was very easy to perform in all women starting from the second application at week 4 and no adverse events were recorded during the study period.

CONCLUSIONS

A 12-week treatment with the fractional CO2 laser was feasible and induced a significant improvement of VVA symptoms by ameliorating vaginal health in postmenopausal women. Further controlled studies should be performed to confirm the present data and to assess the long-term effects of the laser procedure on vaginal tissues.

Urogenital atrophy

The British Menopause Society Council aims to aid health professionals in providing up to date and informed advice about post reproductive health. This guidance refers to the long-term, but often ignored condition of urogenital atrophy resulting from postmenopausal estrogen deficiency. Treatment should be based on up to date information and targeted to the needs of the individual woman. Non-estrogen- and estrogen-containing treatments are discussed.

Vaginal health in the United States: results from the Vaginal Health: Insights, Views & Attitudes survey

OBJECTIVE

The aim of this study was to assess US postmenopausal women's knowledge of and attitudes toward vaginal atrophy, using the Vaginal Health: Insights, Views & Attitudes survey.

METHODS

Data were obtained from 3,520 postmenopausal women (aged 55-65 y) in the United States, Canada, and Europe using a structured Internet-based questionnaire. Results for US women (n = 500) are presented.

RESULTS

Eighty percent of women had finished their menses more than 5 years previously, and 93% had experienced at least one menopausal symptom, although only 63% associated vaginal symptoms with menopause. Of those who had experienced "vaginal discomfort" (48%), vaginal dryness (85%) and pain during intercourse (52%) were most commonly reported. Eighty-two percent of women had experienced vaginal discomfort for 1 year or more. Most women (80%) considered vaginal discomfort to negatively impact their lives, particularly with regard to sexual intimacy (75%), ability to have a loving relationship (33%), and overall quality of life (25%); women also felt that it made them feel old (36%) and affected their self-esteem (26%). Of those with symptoms, 37% did not consult any healthcare professional, and 40% waited 1 year or more before doing so. Although 78% of those with vaginal discomfort used some form of treatment, this consisted mainly of lubricating gels and creams (65%); only 34% of women had used any form of hormone therapy.

CONCLUSIONS

Vaginal atrophy negatively impacts women's lives, but women lack knowledge of the subject and are hesitant to consult healthcare professionals, who should proactively initiate discussions regarding appropriate treatment options.

Gender differences, aging and hormonal status in mucosal injury and repair

As the "baby boomers" age, the percentage of the population over sixty-five years of age is increasing rapidly. Chronic disease management is an important component in the care of the elderly. The effects of aging on different organ systems are also pertinent; such as the weakening homeostatic response to injury in the older individuals. Mucosal surfaces have the largest combined surface area in the body and are the site of important host microbe interactions, especially in the gut which is prone to injury, both from local and systemic insult. This susceptibility has been known to increase with age. Therefore it is important to understand the interplay between aging, injury and recovery at the mucosal surface. Sex hormones play an important role in the maintenance of the mucosal barrier function as well as the mucosa associated immune function in both genders. Menopause in women is a defined time period in which major hormonal changes occur such as a decline in systemic estradiol levels. The differential levels of sex hormones contribute to the sexual dimorphism seen in response to injury at the mucosal surface, prior to and following menopause. Thus the effect of sex hormone and aging on mucosal mechanisms in response to injury is an important area of investigation.

Reviewing the options for local estrogen treatment of vaginal atrophy

BACKGROUND

Vaginal atrophy is a chronic condition with symptoms that include vaginal dryness, pain during sex, itching, irritation, burning, and discharge, as well as various urinary problems. Up to 45% of postmenopausal women may be affected, but it often remains underreported and undertreated. This article aims to review the current recommendations for treatment of vaginal atrophy, and current data on the effectiveness and safety of local vaginal estrogen therapies.

METHODS

Literature regarding vaginal atrophy (2007-2012) was retrieved from PubMed and summarized, with emphasis on data related to the treatment of vaginal atrophy with local vaginal estrogen therapy.

RESULTS

Published data support the effectiveness and endometrial safety of low-dose local estrogen therapies. These results further support the general recommendation by the North American Menopause Society that a progestogen is not needed for endometrial protection in patients using low-dose local vaginal estrogen. Benefits of long-term therapy for vaginal atrophy include sustained relief of symptoms as well as physiological improvements (eg, decreased vaginal pH and increased blood flow, epithelial thickness, secretions).

CONCLUSION

Currently available local vaginal estrogen therapies are well tolerated and effective in relieving symptoms of vaginal atrophy. Recent data support the endometrial safety of low-dose regimens for up to 1 year.

Maintaining sexuality in menopause

Sexual health in the menopause is a medical challenge because the progressive decline of sexual hormones interacts with the aging process and many psychosocial stressors modulate vulnerability for sexual symptoms (low sexual desire, poor arousal and lubrication, dyspareunia, orgasmic dysfunction and lack of satisfaction). In clinical practice, a coordinated approach is needed to optimally manage the risk for developing female sexual dysfunction (FSD), especially when chronic conditions are present. Biomedical and psychosocial interventions include general education, recognition of signs and symptoms, promotion of health, attention to the partner and individualization of treatment. Counselling to overcome personal and relational difficulties should be always combined with hormonal and non-hormonal strategies to maximize biological signals driving the sexual response. By enhancing women's abilities to cope with sexual changes at midlife, health care providers may significantly optimize healthy aging and partnership.

Ospemifene, a non-oestrogen selective oestrogen receptor modulator for the treatment of vaginal dryness associated with postmenopausal vulvar and vaginal atrophy: a randomised, placebo-controlled, phase III trial

OBJECTIVE

To evaluate the efficacy and safety of ospemifene, a novel selective oestrogen receptor modulator, in the treatment of vaginal dryness in postmenopausal women with vulvovaginal atrophy (VVA).

STUDY DESIGN

A 12 week, multicentre, randomised, double-blind, parallel-group phase III study of women (40-80 years) with VVA and self-reported vaginal dryness as their most bothersome symptom.

MAIN OUTCOME MEASURES

The co-primary efficacy endpoints were the change from baseline to Week 12 in (1) percentage of parabasal cells in the maturation index (MI), (2) percentage of superficial cells in the MI, (3) vaginal pH, and (4) severity of vaginal dryness. Safety assessments included physical examination, cervical Papanicolaou test and clinical laboratory analyses. Endometrial thickness and histology was also assessed.

RESULTS

A total of 314 women were randomised to once-daily ospemifene 60 mg/day (n=160) or placebo (n=154). Significant improvements in the percentages of parabasal and superficial cells in the MI and vaginal pH were observed with ospemifene compared with placebo (p<0.001 for all parameters). The mean change from baseline in severity score of vaginal dryness reported by women receiving ospemifene compared with those receiving placebo approached statistical significance (p=0.080). Improvements in each of the four co-primary endpoints with ospemifene were statistically significant compared to placebo in the per protocol population. The majority of treatment-emergent adverse events were considered mild to moderate in severity.

CONCLUSIONS

Once-daily oral ospemifene 60 mg was effective for the treatment of VVA in postmenopausal women with vaginal dryness.

Postmenopausal vaginal atrophy: evaluation of treatment with local estrogen therapy

Postmenopausal vaginal atrophy, resulting from decreased estrogen production, frequently requires treatment. Estrogen preparations provide the most effective treatment; local application is preferred to systemic drugs when treating only vaginal symptoms. As local estrogen therapies have comparable efficacy, this study aimed to understand treatment practices, assess experiences with different forms of local estrogen-delivering applicators, and evaluate satisfaction. Women who were US residents aged ≥18 years, menopausal (no spontaneous menstrual period for ≥1 year or with a double oophorectomy), and receiving local estrogen therapy for 1–6 months (vaginal cream [supplied with a reusable applicator] or vaginal tablets [supplied with a single-use/disposable applicator]), completed an online questionnaire. Data from 200 women (100 cream users and 100 tablet users; mean therapy duration 3.48 months) showed that most stored medication in the room in which it was applied (88%) and applied it at bedtime (71%), a procedure for which cream users required, on average, more than twice the time of tablet users (5.08 minutes versus 2.48 minutes). Many cream users applied larger-than-prescribed amounts of cream, attempting to achieve greater efficacy (42%), or lower-than-recommended doses (45%), most frequently to avoid messiness (33%) or leakage (30%). More tablet users (69%) than cream users (14%) were “extremely satisfied” with their applicator. Postmenopausal women using local estrogen therapy were generally more satisfied with the application of vaginal tablets than cream. Patient satisfaction may help to facilitate accurate dosing. Positive perceptions of medication will help to optimize treatment, which, although not assessed in this study, is likely, in turn, to improve vaginal health.

Menopausal hormone therapy and menopausal symptoms

A majority of women will experience bothersome symptoms related to declining and/or fluctuating levels of estrogen during their menopausal transition. Vasomotor symptoms, vaginal dryness, poor sleep, and depressed mood have all been found to worsen during the menopausal transition. While vasomotor symptoms gradually improve after menopause, the time course can be many years. Vaginal dryness does not improve without treatment, while the long-term course of sleep and mood deterioration is not clearly defined at this time. A small minority of women have vasomotor symptoms that persist throughout the remainder of their lives. These common menopausal symptoms all improve with estrogen treatment. Over the last 10 years, we have witnessed a dramatic reduction in enthusiasm for menopausal hormone therapy, despite its high efficacy relative to other treatments. We have also seen the emergence of sound, evidence-based clinical trials of non-hormonal alternatives that can control the common menopausal symptoms. Understanding the natural history of menopausal symptoms, and the risks and benefits of both hormonal and non-hormonal alternatives, helps the clinician individualize management plans to improve quality of life.

Management of prolapse in older women

Pelvic organ prolapse (POP) is a common problem affecting 37% of women over the age of 80. Review by a specialist with the aid of a validated quality of life questionnaire will help assess bother, as well as the frequency and severity of urinary, bowel and sexual symptoms. Pelvic examination should be carried out to assess the extent of any prolapse and the compartments affected. The main aim of the treatment is to improve the woman's quality of life. Treatment options may be conservative with lifestyle modifications and pelvic floor muscle therapy, use of a pessary or surgery. Treatment has previously been incorrectly limited in the elderly with the misconception that surgery should be avoided. Her current state of health and expectations are most important. Regardless of age, each patient should be assessed individually with a holistic multi-compartment approach and the risk benefit ratios of every treatment considered.