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

Stigmatization as a Barrier to Urologic Care: A Review

Heavy societal stigma of certain conditions has created an environment where individuals may be hesitant to seek professional care. Urology is a specialized field that focuses on many of these conditions that society has deemed taboo to discuss. In this review, we address barriers that have prevented patients from seeking urologic care in order to better understand and elucidate important concerns within development of the physician-patient relationship. Recognizing these concerns can also assist in public health outreach approaches to motivate patients for seeking urologic care. The scope of this review was limited to three highly prevalent conditions affecting both men and women, including urinary incontinence, erectile dysfunction, and genitourinary syndrome of menopause.

Comparison of the Efficacy of Vaginal Hyaluronic Acid to Estrogen for the Treatment of Vaginal Atrophy in Postmenopausal Women: A Systematic Review

Topical estrogen is effective for treating postmenopausal vaginal atrophy. However, there is a potential risk of estrogen-related adverse effects. There is a need for finding effective non-hormonal treatment for vaginal atrophy. The topical application of moisturising agents, such as hyaluronic acid (HA), represents a promising non-hormonal treatment for the relief of vaginal atrophy. This study aimed to summarize the evidence regarding the efficacy of topical HA compared to topical estrogen in postmenopausal women with vaginal atrophy. The literature search covered English-published studies from database inception till February 2023. The search included the electronic databases of MEDLINE/PubMed, Cochrane Library, Web of Science, ProQuest, and Scopus, using the terms "Hyaluronic Acid" AND "Postmenopause" AND "Vagina" AND "Atrophy". Due to the diversity in reporting outcomes, meta-analysis was not feasible. A narrative synthesis with a systematic approach was conducted by vote counting of studies that included a direct comparison between topical HA and topical estrogen. Six studies were included. Intra-group comparisons showed that both interventions were significantly effective in alleviating the symptoms of vaginal atrophy and dyspareunia as well as improving vaginal pH and cell maturation index. However, inter-group comparisons in most studies showed that estrogen was superior to HA in relieving vaginal symptoms and improving vaginal pH, dyspareunia, and the cell maturation index. There is no evidence to show the superiority of HA to estrogen in the treatment of postmenopausal vaginal atrophy. However, the therapeutic efficacy of HA seems to be comparable to estrogen and considering its safety, HA can be used as an alternative to estrogen in patients who do not want to use estrogen. The available studies have several limitations, and the reporting of outcomes was considerably heterogeneous.

Assessing vaginal wall thickness by transvaginal ultrasound in breast cancer survivors: A pilot study

AIM

There is need for a straightforward objective measure to evaluate vaginal wall changes related to hypoestrogenism. The aim of this pilot study was to evaluate a transvaginal ultrasound procedure for the quantification of vaginal wall thickness in order to differentiate between healthy premenopausal women and postmenopausal women with genitourinary syndrome of menopause using ultra-low-level estrogen status as a model.

METHODS

We performed a prospective, two-arm, cross-sectional pilot study comparing vaginal wall thickness measured by transvaginal ultrasound in postmenopausal breast cancer survivors using aromatase inhibitors with genitourinary syndrome of menopause (GSM group) and healthy premenopausal women (control or C group) from October 2020 to March 2022. After intravaginal introduction of 20 cm³ of sonographic gel, vaginal wall thickness was measured by transvaginal ultrasound in the anterior, posterior, and right and left lateral walls (four quadrants). The study methods followed the STROBE checklist.

RESULTS

According to the results of a two-sided t-test, the mean vaginal wall thickness of the four quadrants in the GSM group was significantly less than that of the C group (2.25 mm vs 4.17 mm, respectively; p < 0.001). Likewise, the thickness of each of the vaginal walls (anterior, posterior, right and left lateral) statistically differed between the two groups (p < 0.001).

CONCLUSION

Transvaginal ultrasound with intravaginal gel may be a feasible objective technique to assess genitourinary syndrome of menopause, showing clear differences in vaginal wall thickness between breast cancer survivors using aromatase inhibitors and premenopausal women. Possible correlations with symptoms or treatment response should be assessed in future studies.

Relationship between personality traits and sexual function in symptomatic postmenopausal women

INTRODUCTION

Female sexual function relies on a complex interplay of physical, psychosocial, and neurobiological factors. Over the last decades, increasing attention has been paid to the influence of personality traits on general health and many aspects of quality of life, including sexuality.

OBJECTIVE

To assess whether dimensions of the personality are related to the domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain) in symptomatic postmenopausal women. Mood was also investigated to explore its association with female sexual dysfunction (FSD).

METHODS

Validated questionnaires to assess sexual function [the Female Sexual Functioning Index (FSFI)], mood [the State-Anxiety Inventory (STAI), and Zung Self Rating Depression Scale (SDS)], and personality traits [the Tridimensional Personality Questionnaire (TPQ)] were filled in by 130 early postmenopausal women experiencing hot flushes (≥30/week).

RESULTS

61.5 % (n = 80) of the women had an FSFI total score lower than 26.55, the standard cut-off for FSD. A clinical state of anxiety was present in 53.8 % (n = 70), whereas only 12.3 % (n = 16) showed clinically relevant depressive symptoms. According to the FSFI cut-off score, women with sexual disorders had statistically significantly higher levels of anxiety, depression (p < 0.001 for both), and harm avoidance (HA) (p = 0.004) than women without such disorders. Significantly higher levels of anxiety were found in women in the lower quartile (LQ) of the distribution of the total FSFI score than in women in both the interquartile range (IQR) and in the upper quartile (UQ) (p < 0.05). Moreover, women in the UQ had a lower grade of depression and HA than others (p < 0.05). The Sobel test showed that the personality trait HA significantly mediated the relationship between anxiety and FSFI total score (Z = -2.19, p < 0.05) and between depression and FSFI total score (Z = -2.35, p < 0.05).

CONCLUSIONS

The present data suggest the personality trait HA is relevant to sexual function and mediates the impact of mood on FSD in symptomatic menopausal women. In clinical practice, the use of validated psychometric tools for mood screening is useful to establish appropriate diagnosis and treatment of sexual disorders in menopausal women. Moreover, the assessment of personality traits could provide additional information that directs clinicians towards an increasingly tailored and multidimensional treatment of FSD.

Vaginal hormone-free moisturising cream is not inferior to an estriol cream for treating symptoms of vulvovaginal atrophy: Prospective, randomised study

This prospective, open-label, multicentre, multinational, randomised trial investigated the non-inferiority of treatment with a vaginal hormone-free moisturising cream compared to a vaginal estriol (0.1%) cream in a panel of post-menopausal women suffering from symptoms of vulvovaginal dryness in a parallel group design. In total, 172 post-menopausal women were randomly allocated to either one of the two treatments, each administered for 43 days. The primary endpoint was the total severity score of subjective symptoms (dryness, itching, burning and pain unrelated to sexual intercourse) of the respective treatment period. Secondary endpoints were severity of single subjective symptoms (including dyspareunia if sexually active), impairment of daily life, Vaginal Health Index, as well as assessment of safety. In both groups, women treated with hormone-free moisturising cream and those treated with estriol cream, total severity score improved significantly compared to baseline by 5.0 (from 6.1 to 1.1) and by 5.4 (from 6.0 to 0.6), respectively, after 43 days of treatment (p < 0.0001). One-sided test of baseline differences (for a clinically relevant difference Δ = 1.5) confirmed the hormone-free moisturising cream to be non-inferior to the estriol cream. Severity of dyspareunia as well as impairment of daily life due to subjective symptoms, significantly improved for both treatment groups (p<0.0001). Subgroup analysis of women with mild or moderate impairment of daily life at baseline caused by "vaginal dryness" symptoms benefited from both creams, while women with severe impairment showed a significantly greater benefit from the estriol cream (p = 0.0032). Both treatments were well tolerated with no serious adverse events occurring. This study provides clinical evidence that a hormone-free vaginal moisturising cream cannot only improve vaginal dryness compared to an 0.1% estriol cream but also can relieve dyspareunia as well as improve woman's impairment of daily life, justifying its use as a first choice for mild or moderate vulvovaginal dryness symptoms.

Limitations in functioning in climacteric syndrome: a systematic literature review using the ICF

INTRODUCTION

This study is the first of four preparatory studies in the process to develop an International Classification of Functioning, Disability and Health (ICF) Core Set for climacteric syndrome. The aim was to identify perimenopausal and postmenopausal limitations in functioning reported in the scientific literature.

METHODS

A systematic literature review was performed on MEDLINE, PsycInfo, Embase and CINAHL including publications from 2010 to 2020. Meaningful concepts were identified from the included studies and linked to the ICF using standardized linking rules.

RESULTS

From the 6935 unique publications found, 300 articles were randomly selected for abstract screening and 48 studies met the inclusion criteria. From these, 1836 meaningful concepts were identified and linked to 158 different ICF categories. Most of them could be linked to the ICF chapter 'Body Functions'. Emotional, sleep, energy and drive as well as thermoregulatory functions and sensation of pain were addressed in >80% of all publications.

CONCLUSION

Climacteric syndrome involves all four components of the ICF, but the focus of scientific research lies on limitations in body functioning. Limitations in body structures, activities and participation and environmental factors were less frequently assessed. The ICF is a valuable tool to describe the multidimensional phenotype of climacteric syndrome.

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

OBJECTIVES

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

STUDY DESIGN

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

[Genitourinary menopause syndrome. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

INTRODUCTION

Genitourinary menopause syndrome (SGUM) is defined as a set of symptoms associated with a decrease of estrogen and other sexual steroids during menopause. The main symptoms are vulvovaginal (dryness, burning, itching), sexual (dyspareunia), and urinary (urinary infections, pollakiuria, nycturia, pain, urinary incontinence by urgenturia). SGUM leads to an alteration of the quality of life, and affects especially women's sexuality.

OBJECTIVE

The objective of this review was to elaborate guidelines for clinical practice regarding the management of SGUM in postmenopausal women, and in particular, in women with a history of breast cancer, treated or not with hormone therapy.

MATERIALS AND METHODS

A systematic review of the literature on SGUM management was conducted on Pubmed, Medline and Cochrane Library. Recommendations from international scholarly societies were also taken into account: International Menopause Society (IMS) https://www.imsociety.org, The North American Menopause Society (NAMS) https://www.menopause.org, Canadian Menopause Society https://www.sigmamenopause.com, European Menopause and Andropause Society (EMAS) https://www.emas-online.org, International Society for the Study of Women's Sexual Health (ISSWSH) https://www.isswsh.org.

RESULTS

Vaginal use of lubricants, moisturizers and hyaluronic acid improves the symptoms of SGUM and may be offered to all patients. For postmenopausal women, local estrogen will be preferred to the oral route because of their safety and efficacy on all symptoms of SGUM during low-dose use. Prasterone is a local treatment that can be proposed as an effective alternative for the management of dyspareunia and sexual function disorder. Current data on oral testosterone, tibolone, oral or transdermal DHEA and herbal medicine are currently limited. Ospemifène, which has shown a significant improvement in sexual symptoms, is not currently marketed in France. In the particular case of women with a history of breast cancer, non-hormonal regimens are a first-line therapy. Current data on the risk of breast cancer recurrence when administering low-dose local estrogen are reassuring but do not support a conclusion that this treatment is safe.

CONCLUSION

SGUM is a common symptom that can affect the quality of life of postmenopausal women. A treatment should be systematically proposed. Local non-hormonal treatment may be offered in all women. Local low-dose estrogen therapy and Prasterone has shown an interest in the management of symptoms. In women before a history of breast cancer, local non-hormonal treatment should be offered first-line. The safety of low-dose local estrogen therapy and Prasterone cannot be established at this time. Other alternatives exist but are not currently recommended in France due to lack of data.

Efficacy and safety of a new vaginal gel for the treatment of symptoms associated with vulvovaginal atrophy in postmenopausal women: A double-blind randomized placebo-controlled study

OBJECTIVE

The aim of the present randomized placebo-controlled single-center study was to assess the efficacy and safety of a new vaginal gel (Meclon Idra - Alfasigma) in the treatment of vulvovaginal atrophy (VVA). The gel is composed of sea buckthorn (Hippophaë rhamnoides) oil, aloe vera, 18β-glycyrrhetic acid, hyaluronic acid and glycogen. The study assessed whether the gel can reduce VVA symptoms (vaginal dryness, itching, burning sensation) and improve sexual function in postmenopausal women over 12 weeks.

STUDY DESIGN

Postmenopausal women (n° = 60) reporting VVA symptoms were recruited and randomized in a 1:1 ratio to the gel or placebo. Active vaginal gel or placebo was applied for 14 days and then twice a week for 90 consecutive days.

MAIN OUTCOME MEASURE

The Vaginal Health Index (VHI), including vaginal pH, was used to assess changes in objective signs, whereas the self-reported Female Sexual Function Index (FSFI) was used to investigate sexual function.

RESULTS

Meclon Idra was effective in reducing vaginal pain, dyspareunia and vaginal pH, with the VHI showing significant improvement at day 90 (P < .0001), and in reducing each VVA symptom (vaginal dryness, vaginal itching, burning sensation) at weeks 2 and 4, and the end of the study (P < .0001). The analysis of FSFI scores showed, after the end of treatment, an improvement of sexual function in the active-treatment group, with a statistically significant increase (P < 0.001) in all domains scores and total score (P < 0.001).

CONCLUSIONS

The present single-center randomized clinical trial demonstrated the efficacy, tolerability and safety of 12-week treatment with a new vaginal gel in postmenopausal women with symptoms associated with VVA. Based on this trial, the gel seems to be a valid choice as a single, local agent for relieving VVA symptoms and improving sexual function, and to have good compliance. This trial is registered prospectively with the Clinical Trials Registry - India, number CTRI/2019/05/01911.

Viewing symptoms associated with Vulvovaginal Atrophy (VVA)/Genitourinary syndrome of menopause (GSM) through the estro-androgenic lens - Cluster analysis of a web-based Italian survey among women over 40

OBJECTIVE

we aimed to explore the use of an estro-androgenic symptom questionnaire in women (EASQ-W), including items typically associated with menopausal hypoestrogenism and some others possibly related to androgen insufficiency that may be relevant to further characterize women reporting VVA/GSM at midlife.

METHODS

web-based survey involving a representative sample of 1505 Italian women (age range: 40-65 years). The responders completed a structured, online questionnaire, reporting symptoms (yes/no option) and rating them (from 1 to 10), if present during the past 4 weeks. A factor analysis methodology (principal component analysis and K-MEANS clustering algorithm) was used to segment women. Statistically significant differences between groups were determined at the 95 % level of confidence.

RESULTS

more than half of our study sample were aged 50-65 years (n = 901; 59.9 %) and 55 % were postmenopausal women (PMW). We obtained 8 principal domains of the EASQ-W with PMW reporting significantly more severe symptoms in the majority of domains related to well-being at mid-life. The K-MEANS clustering algorithm identified 4 clusters of women characterized by different symptoms: vasomotor (VMS; n = 341), sexual (SEX; n = 301), poorly symptomatic (LOWSYMPT; n = 766), sexual and anatomic, mainly at genital level (SEX + ANAT; n = 97), independently from the menopausal status. The cluster SEX + ANAT was the one reporting overall more symptoms in each of the other principal domains. Some symptoms (impression of being diminished in height, deterioration in work performance, more memory lapses/confusion than before, more wrinkles/signs of aging in the mirror, put on more tummy than usual) and the entire urological (UROL) cluster were significantly more reported by women in the cluster SEX + ANAT. Even when only severe symptoms were analysed, women in the SEX + ANAT cluster were the ones more symptomatic. The SEX only cluster identified younger women, with significantly less day and night hot flushes and sweats and less vaginal dryness and low lubrication associated with sexual pain as compared to SEX + ANAT.

CONCLUSION

our results provide insight into the constellation of symptoms associated with VVA/GSM by identifying women with distinct clusters of complaints that may require a tailored diagnostic and therapeutic approach across age and menopause.

Ospemifene plus fractional CO2 laser: a powerful strategy to treat postmenopausal vulvar pain

This study is a single-center, retrospective analysis of postmenopausal women presenting with dyspareunia and vulvar pain, aiming to evaluate relative effectiveness of vestibular CO₂ laser therapy as a treatment. Three monthly sessions of laser were performed to each patient and thereafter a three-months follow-up was stablished. A total number of 72 patients undergoing vestibular laser treatment were recruited from patient files in the period between 2016 and 2018. Among these, 39 women also received a concomitant treatment with ospemifene (60 mg/day) during the study period. There was a statistically significant reduction of all the symptoms in both groups up to the three month follow-up. Regarding dryness and dyspareunia, the relief tent to be more prominent in the ospemifene + laser group at all follow-ups and remained statistically significant at three-month follow-up. Specifically, vestibular dryness was significantly lower in the ospemifene + laser group compared with the laser treatment group (-87% vs - 34%, respectively), and the vestibular health score started declining faster in the ospemifene + laser group. Although, additional research is needed to understand the mechanism of action, our data shows that a combination regimen of laser and ospemifene may improve clinical effectiveness for long-term treatment of symptoms associated with the under-recognized genitourinary syndrome of menopause.

Effects of Hypothyroidism and Subclinical Hypothyroidism on Sexual Function: A Meta-Analysis of Studies Using the Female Sexual Function Index

Introduction

Hypothyroidism and subclinical hypothyroidism (SCH) are common metabolic diseases with severe psychological and physiological effects, which may be the risk factors of sexual dysfunction.

Aim

The purpose of this study is to explore the influence of hypothyroidism and SCH on female sexual function through systematic literature review.

Methods

Until February 2020, systematic searches were conducted on Pubmed, Web of Science, EMBASE, and Clinicalkey to obtain eligible studies to report the mean and standard deviation of Female Sexual Function Index (FSFI) in various fields in women with clinical hypothyroidism, SCH, and healthy controls. In accordance with the results of heterogeneity test, a random effect model or fixed effect model was selected to aggregate the scores of each field. The scores of female patients with hypothyroidism and healthy controls were compared using forest plot. Stata (version 15.1) uses meta-analysis.

Main Outcome Measure

Evaluation values of various fields of FSFI in clinical hypothyroidism, SCH, and healthy controls.

Results

This study included 7 studies, including 88 women with clinical hypothyroidism, 337 women with SCH, and 2056 healthy controls. Compared with healthy controls, patients with hypothyroidism scored lower in all FSFI dimensions (desire, arousal, lubrication, orgasm, satisfaction, and pain), especially in lubrication. And, only arousal and orgasm decreased in patients with SCH. Hypothyroidism (odds ratio = 3.912, P = .002) rather than SCH (odds ratio = 1.036, P = .886) was a risk factor for female sexual dysfunction.

Conclusion

Hypothyroidism does impair female sexual function to varying degrees. SCH has little effect on female sexual function. It is essential to measure and evaluate the thyroid function of women with sexual dysfunction regularly, which can help clinicians improve sexual function and sexual quality of life.

Wang Y and Wang H. Effects of Hypothyroidism and Subclinical Hypothyroidism on Sexual Function: A Meta-Analysis of Studies Using the Female Sexual Function Index. Sex Med 2020;8:156–167.

Does Type of Menopause Affect the Sex Lives of Women?

Background

The aim of this study was to investigate factors affecting the sex lives of middle-aged women, and whether surgical menopause affects sexual function differently from natural menopause, by comparing effects on sexual performance of women with similar demographic features.

Material/Methods

The study included 151 women with surgical menopause (SM), 357 women with natural menopause (NM), and 186 perimenopausal women (PM). The women were asked to complete a 6-question survey of sexual performance parameters. The relationship between the demographic and clinical features and hormone levels of the groups and sexual function parameters were evaluated. We also compared these parameters between the 3 study groups, and paired comparisons were made between the SM group and the NM group.

Results

Demographic features, serum DHEA-S, total testosterone, and FSH levels were found to have statistically significant effects on sexual performance of women (p<0.05). The sexual function scores for the frequency of sexual desire, coitus, and orgasm were significantly higher in the PM group, whereas vaginal lubrication scores were lower compared to the NM and SM group (p<0.05). In paired comparison of NM and SM, the scores for the frequency of coitus, orgasm, and vaginal lubrication were significantly higher in the SM group, while sexual desire frequency scores were higher in the NM group (p<0.05).

Conclusions

Our study approached to this topic in an extended manner and found significant relationships between several demographic-clinical and hormonal factors. SM was found to not affect female sexual performance, except for sexual desire, more than NM.

Impact Of Vulvovaginal Atrophy Of Menopause In Spanish Women: Prevalence And Symptoms According To The EVES Study

Introduction

The prevalence of menopausal women with confirmed vulvovaginal atrophy (VVA) oscillates between 67–98%.

Aim

To assess the prevalence of postmenopausal women with VVA confirmed by gynecologic clinical assessment among all women attending menopause centers in Spain, as well as to describe the impact of VVA on quality of life and sexual functioning.

Methods

Women aged 45–75 years old with the last menstrual period >12 months before were included in a cross-sectional study.

Main Outcome Measures

Women with ≥1 VVA symptoms filled out a number of questionnaires, including EuroQoL, Day-to-Day Impact of Vaginal Aging, Female Sexual Function Index, and Female Sexual Distress Scale-revised. A gynecologic examination was performed to confirm diagnosis.

Results

1,177 evaluable patients were included. VVA was confirmed in 87.3% of the patients. Almost 80% of women who acknowledged being sexually active (n = 717) presented pain during intercourse. As compared with patients without confirmed VVA (n = 66), patients with confirmed VVA (n = 1,028) were significantly older (P < .0001), had lower rates of sexual activity (P < .05), and used more VVA treatments (P < .05). Severe vaginal atrophy and severe vulvar atrophy were more prevalent in VVA-confirmed women (P < .0001, in both cases). No differences regarding the confirmation of VVA were observed for EuroQoL and Day-to-Day Impact of Vaginal Aging quality-of-life questionnaires. Sexual function measured through the Female Sexual Function Index score was significantly reduced in sexually-active patients with confirmed VVA (P < .05).

Conclusion

VVA signs and symptoms are highly prevalent in Spanish postmenopausal women. Confirmation of VVA diagnosis was associated with impaired sexual function. The early recognition of VVA symptoms should be actively promoted in medical practice, instead of waiting until signs appear to exclude other reasons for VVA and to manage treatment effectively.

Palacios S, González SP, Fernández-Abellán M, et al. Impact of Vulvovaginal Atrophy of Menopause in Spanish Women: Prevalence and Symptoms According to the EVES Study. Sex Med 2019;7:207–216.

Addressing Vulvovaginal Atrophy (VVA)/Genitourinary Syndrome of Menopause (GSM) for Healthy Aging in Women

Vaginal health is an essential component of active and healthy aging in women at midlife and beyond. As a consequence of hormonal deprivation and senescence, the anatomy and function of urogenital tissues are significantly affected and vulvovaginal atrophy (VVA) may occur. In a high proportion of postmenopausal women, progressive and chronic VVA symptoms have a strong impact on sexual function and quality of life. The new definition of genitourinary syndrome of menopause (GSM) comprises genital symptoms (dryness, burning, itching, irritation, bleeding), sexual symptoms (dyspareunia and other sexual dysfunctions) and urinary symptoms (dysuria, frequency, urgency, recurrent urinary infections). Many variables (age, sexual activity and partnership status) influence the clinical impact VVA/GSM symptoms and attitudes of elderly women to consult for receiving effective treatments. Psychosocial factors play a critical role in sexual functioning, but the integrity of the urogenital system is as well important affecting many domains of postmenopausal women's health, including sexual function. Several international surveys have extensively documented the need to improve VVA/GSM management because of the strong impact on women's daily life and on couple's intimacy. Health care providers (HCPs) need to be proactive in the early recognition of VVA/GSM in order to preserve urogenital and sexual longevity, by using hormonal and non-hormonal strategies. The clinical diagnosis is based on genital examination to identify objective signs and on the use of subjective scales to rate most bothersome symptoms (MBS), especially vaginal dryness. Recent studies point to the importance of addressing VVA/GSM as a potential early marker of poor general health in analogy with vasomotor symptoms. Therefore, a standard of VVA/GSM care in elderly women is desirable to enhance physical, emotional and mental well-being.

[CO2 LASER for the treatment of vaginal symptoms of genitourinary syndrome of menopause]

Genitourinary syndrome of menopause (GSM) brings together a collection of signs including vaginal dryness, burning sensation and itching discomfort as well as deterioration of sexual health, dysuria, urgenturia and repeated urinary infections and may be responsible for a significant impairment of quality of life in symptomatic postmenopausal women. The management of GSM therefore represents a public health issue. Systemic or local hormonal treatments are frequently offered, as well as non-hormonal treatments. The existence of contraindications to hormonal treatments and the constraints of using local treatments lead us to propose other therapeutic options. CO₂ LASER is now part of the therapeutic arsenal for the treatment of vaginal dryness in the context of GSM. There is a growing interest in this technique, especially for women who have a contraindication to hormonal therapy, as it is a globally effective, long-acting alternative with very little adverse effect. Current evidence suggests that this tool could provide a quality of life benefit to many patients with minimal side effect exposure, if used in the respect of its indications and implementation protocols. However, clinical data based on high-level therapeutic trials remain absolutely essential for this treatment to be validated and recommended by health professionals.

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.

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.

Factors associated with urinary incontinence in middle-aged women: a population-based household survey

INTRODUCTION AND HYPOTHESIS

The objective was to determine the prevalence of urinary incontinence (UI) and factors associated in a sample of Brazilian middle-aged women.

METHODS

A cross-sectional study was conducted between September 2012 and June 2013 with 749 women. UI was defined as any complaint of involuntary loss of urine. The independent variables were sociodemographic data and health-related habits and problems. Statistical analysis was carried out using Chi-squared test and Poisson regression.

RESULTS

The mean age was 52.5 (±4.4) years. The prevalence of UI was 23.6 %. Of these, 48 (6.4 %) had stress urinary incontinence, 59 (7.8 %) urinary urgency, and 70 (9.5 %) had mixed urinary incontinence. In the final statistical model, self-perception of health as fair/poor/very poor (PR: 1.90; 95 % CI, 1.45-2.49; P < 0.001), ≥1 vaginal deliveries (PR: 1.84; 95 % CI, 1.35-2.50; P < 0.001), higher body mass index (PR: 1.04; 95 % CI, 1.02-1.06; P = 0.001), vaginal dryness (PR: 1.60; 95 % CI, 1.23-2.08; P = 0.001), current or previous hormone therapy (PR: 1.38; 95 % CI, 1.06-1.81; P = 0.019), pre-/perimenopause (PR: 1.42; 95 % CI, 1.06-1.91; P = 0.021), and previous hysterectomy (PR: 1.41; 95 % CI, 1.03-1.92; P = 0.031) were associated with a greater prevalence of UI. Current or previous use of soy products to treat menopausal symptoms was associated with a lower prevalence of UI (PR: 0.43; 95 % CI, 0.24-0.78; P = 0.006).

CONCLUSIONS

Several factors are associated with UI in middle-aged Brazilian women. The results highlight the importance of carrying out interventions aimed at reducing modifiable factors.

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.