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Kagan R, Simon JA, Goldstein SR, Komm BS, Jenkins SN, Portman DJ. Oral lasofoxifene's effects on moderate to severe vaginal atrophy in postmenopausal women: two phase 3, randomized, controlled trials. Menopause 2024; 31:494-504. [PMID: 38652875 DOI: 10.1097/gme.0000000000002355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE The aim of this study was to demonstrate whether lasofoxifene improves vaginal signs/symptoms of genitourinary syndrome of menopause. METHODS Two identical, phase 3 trials randomized postmenopausal women with moderate to severe vaginal symptoms to oral lasofoxifene 0.25 or 0.5 mg/d, or placebo, for 12 week. Changes from baseline to week 12 in most bothersome symptom, vaginal pH, and percentages of vaginal parabasal and superficial cells were evaluated. These coprimary endpoints were analyzed using analysis of covariance, except superficial cells, which were analyzed by the nonparametric, rank-based Kruskal-Wallis test. RESULTS The two studies enrolled 444 and 445 women (mean age, ~60 y), respectively. Coprimary endpoints at week 12 improved with lasofoxifene 0.25 and 0.5 mg/d greater than with placebo ( P < 0.0125 for all). Study 1: most bothersome symptom (least square mean difference from placebo: -0.4 and -0.5 for 0.25 and 0.5 mg/d, respectively), vaginal pH (-0.65, -0.58), and vaginal superficial (5.2%, 5.4%), and parabasal (-39.9%, -34.9%) cells; study 2: most bothersome symptom (-0.4, -0.5), vaginal pH (-0.57, -0.67), and vaginal superficial (3.5%, 2.2%) and parabasal (-34.1%, -33.5%) cells. Some improvements occurred as early as week 2. Most treatment-emergent adverse events were mild or moderate and hot flushes were most frequently reported (lasofoxifene vs placebo: 13%-23% vs 9%-11%). Serious adverse events were infrequent and no deaths occurred. CONCLUSIONS In two phase 3 trials, oral lasofoxifene 0.25 and 0.5 mg/d provided significant and clinically meaningful improvements in vaginal signs/symptoms with a favorable safety profile, suggesting beneficial effects of lasofoxifene on genitourinary syndrome of menopause.
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Affiliation(s)
- Risa Kagan
- From the University of California, San Francisco and Sutter East Bay Medical Foundation, Berkeley, CA
| | - James A Simon
- George Washington University, School of Medicine; IntimMedicine Specialists, Washington, DC
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Gaspard U, Taziaux M, Jost M, Coelingh Bennink HJ, Utian WH, Lobo RA, Foidart JM. A multicenter, randomized, placebo-controlled study to select the minimum effective dose of estetrol in postmenopausal participants (E4Relief): part 2-vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life. Menopause 2023; 30:480-489. [PMID: 36809193 PMCID: PMC10155698 DOI: 10.1097/gme.0000000000002167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/14/2022] [Indexed: 02/23/2023]
Abstract
OBJECTIVE A phase 2 study showed that 15 mg estetrol (E4) alleviates vasomotor symptoms (VMS). Here, we present the effects of E4 15 mg on vaginal cytology, genitourinary syndrome of menopause, and health-related quality of life. METHODS In a double-blind, placebo-controlled study, postmenopausal participants (n = 257, 40-65 y) were randomized to receive E4 2.5, 5, 10, or 15 mg or placebo once daily for 12 weeks. Outcomes were the vaginal maturation index and maturation value, genitourinary syndrome of menopause score, and the Menopause Rating Scale to assess health-related quality of life. We focused on E4 15 mg, the dose studied in ongoing phase 3 trials, and tested its effect versus placebo at 12 weeks using analysis of covariance. RESULTS Least square (LS) mean percentages of parabasal and intermediate cells decreased, whereas superficial cells increased across E4 doses; for E4 15 mg, the respective changes were -10.81% ( P = 0.0017), -20.96% ( P = 0.0037), and +34.17% ( P < 0.0001). E4 15 mg decreased LS mean intensity score for vaginal dryness and dyspareunia (-0.40, P = 0.03, and -0.47, P = 0.0006, respectively); symptom reporting decreased by 41% and 50%, respectively, and shifted to milder intensity categories. The overall Menopause Rating Scale score decreased with E4 15 mg (LS mean, -3.1; P = 0.069) and across doses was associated with a decreasing frequency and severity of VMS ( r = 0.34 and r = 0.31, P < 0.001). CONCLUSIONS E4 demonstrated estrogenic effects in the vagina and decreased signs of atrophy. E4 15 mg is a promising treatment option also for important menopausal symptoms other than VMS.
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Affiliation(s)
- Ulysse Gaspard
- From the Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | | | - Maud Jost
- Estetra SRL, Mithra Pharmaceuticals, Liège, Belgium
| | | | - Wulf H. Utian
- Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Jean-Michel Foidart
- From the Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
- Estetra SRL, Mithra Pharmaceuticals, Liège, Belgium
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Nappi RE, Guida M, Marchesoni D, Cianci A, Pellegrino A, Remorgida V, Di Paolantonio T, Benedetti Panici P. Vulvovaginal atrophy of menopause and its impact on sexual function in an Italian clinical cohort of post-menopausal women. J OBSTET GYNAECOL 2021; 41:290-297. [PMID: 33432869 DOI: 10.1080/01443615.2020.1832973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of current study was to estimate the impact of vulvovaginal atrophy (VVA) on sexual function in a clinical population of Italian postmenopausal women. Women aged 45-75 years with at least one VVA symptom completed three questionnaires: Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI) and Female Sexual Distress Scale revised (FSDS-R). A gynaecological examination was performed for VVA confirmation. Among the 1,066 evaluable patients, VVA was confirmed in around 90% of the sample. Sexual function impairment was significantly higher in patients with confirmed VVA as observed by significant differences in the sexual function component of the DIVA questionnaire (p = .014), the FSDS-R (p < .0005), and the FSFI (p < .0005), as well as for all the FSFI subdomains: desire (p < .0005), arousal (p < .0005), lubrication (p < .0005), orgasm (p < .0005), satisfaction (p < .0005) and pain (p < .0005). Significant impairment of sexual function was demonstrated in Italian postmenopausal women who were clinically confirmed with signs of VVA through gynaecological examination.IMPACT STATEMENTWhat is already known on this subject: At least half of postmenopausal women report VVA associated symptoms with significant impact on sexual function and ultimately on sexual activity.What the results of this study add: As compared with patients without confirmed VVA, the negative impact on sexual function was significantly higher in patients with confirmed VVA. This difference was observed for the sexual function component (DIVA-C) of the DIVA questionnaire, for the overall FSDS-R result, and for the overall FSFI score, as well as for all the FSFI subdomains (desire, arousal, lubrication, orgasm, satisfaction and pain).What the implications are of these findings for clinical practice and/or further research: An impairment of sexual function is significantly associated with VVA diagnosis in Italian post-menopausal women, especially when diagnosis was objectively confirmed by clinical signs of VVA visible in the gynaecological examination. In addition, this study demonstrates that inquiring about VVA using a structured questionnaire may increase the diagnosis of VVA related changes in sexual function.
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Affiliation(s)
- Rossella E Nappi
- Research Center for Reproductive Medicine, Gynaecological Endocrinology and Menopause, IRCCS S. Matteo Foundation, Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Maurizio Guida
- Division of Gynecology and Obstetrics, Department of Medicine and Surgery, "SS. Giovanni di Dio e Ruggi d'Aragona - Schola Medica Salernitana", University of Salerno Hospital, Salerno, Italy
| | - Diego Marchesoni
- Department of Experimental Clinical and Medical Science, DISM, Clinic of Obstetrics and Gynecology, University of Udine, Udine, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | | | - Valentino Remorgida
- Unit of Obstetrics and Gynecology, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genova, Genova, Italy
| | | | - Pierluigi Benedetti Panici
- University of Rome "Sapienza", Department of Gynaecological-Obstetric Sciences and Urological Sciences, Umberto I Hospital, Rome, Italy
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Yeganeh L, Khan NN, Boyle JA, Gibson-Helm M, Teede H, Vincent AJ. Development and evaluation of an early menopause question prompt list. ACTA ACUST UNITED AC 2020; 27:102-109. [DOI: 10.1097/gme.0000000000001429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The burden of vulvovaginal atrophy on women's daily living: implications on quality of life from a face-to-face real-life survey. Menopause 2019; 26:485-491. [DOI: 10.1097/gme.0000000000001260] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Portman DJ, Goldstein SR, Kagan R. Treatment of moderate to severe dyspareunia with intravaginal prasterone therapy: a review. Climacteric 2018; 22:65-72. [PMID: 30554531 DOI: 10.1080/13697137.2018.1535583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The loss of sex steroids (e.g. estradiol, dehydroepiandrosterone [DHEA], progesterone) that causes menopause commonly affects a woman's general health and produces bothersome physical changes that may interfere with normal sexual and genitourinary functioning. Although both over-the-counter and prescription treatments are available, there remains a large unmet need, as less than 10% of women are treated. Adrenal DHEA and its sulfate are the most abundant steroids in humans. Here we review the development of intravaginal prasterone, the synthetic equivalent to endogenous DHEA. Prasterone is approved by the US Food and Drug Administration for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause. Prasterone has been shown to decrease the pain associated with dyspareunia, and to improve vaginal pH, as well as superficial and parabasal cell counts, while maintaining serum hormone levels within the range of those seen in normal postmenopausal women. Unlike other menopausal prescription therapies, intravaginal prasterone does not carry a boxed warning, thus allowing the clinician and patient to engage in meaningful and reassuring discussion around a new approach that treats this common, debilitating condition.
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Affiliation(s)
- D J Portman
- a Columbus Center for Women's Health Research , Columbus , OH , USA.,b Sermonix Pharmaceuticals , Columbus , OH , USA
| | - S R Goldstein
- c Department of Obstetrics and Gynecology , New York University School of Medicine , New York , NY , USA
| | - R Kagan
- d Department of Obstetrics, Gynecology, and Reproductive Sciences , University of California , San Francisco , CA , USA.,e Sutter East Bay Medical Foundation , Berkeley , CA , USA
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Mitchell CM, Reed SD, Diem S, Larson JC, Newton KM, Ensrud KE, LaCroix AZ, Caan B, Guthrie KA. Efficacy of Vaginal Estradiol or Vaginal Moisturizer vs Placebo for Treating Postmenopausal Vulvovaginal Symptoms: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:681-690. [PMID: 29554173 PMCID: PMC5885275 DOI: 10.1001/jamainternmed.2018.0116] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Nearly half of postmenopausal women report bothersome vulvovaginal symptoms, but few data support the efficacy of 2 commonly recommended treatments. OBJECTIVE To compare the efficacy of a low-dose vaginal estradiol tablet and a vaginal moisturizer, each vs placebo, for treatment of moderate-to-severe postmenopausal vulvovaginal symptoms. DESIGN, SETTING, AND PARTICIPANTS This 12-week multicenter randomized clinical trial enrolled postmenopausal women with moderate to severe symptoms of vulvovaginal itching, pain, dryness, irritation, or pain with penetration. INTERVENTIONS Vaginal 10-μg estradiol tablet (daily for 2 weeks, then twice weekly) plus placebo gel (3 times a week) (n = 102) vs placebo tablet plus vaginal moisturizer (n = 100) vs dual placebo (n = 100). MAIN OUTCOMES AND MEASURES The main outcome was decrease in severity (0-3) of most bothersome symptom (MBS) between enrollment and 12 weeks. Additional measures included a composite vaginal symptom score, Female Sexual Function Index (FSFI) score (2-36), modified Female Sexual Distress Score-Revised item 1, treatment satisfaction and meaningful benefit, Vaginal Maturation Index, and vaginal pH. RESULTS The 302 women had a mean (SD) age of 61 (4) years and were primarily white (267 [88%]), college educated (200 [66%]), and sexually active (245 [81%]). Most women (294 [97%]) provided data for the primary analysis. The most commonly reported MBS was pain with vaginal penetration (182 [60%]), followed by vulvovaginal dryness (63 [21%]). Mean baseline MBS severity was similar between treatment groups: estradiol, 2.4 (95% CI, 2.3 to 2.6); moisturizer, 2.5 (95% CI, 2.3 to 2.6); placebo, 2.5 (95% CI, 2.4 to 2.6). All treatment groups had similar mean reductions in MBS severity over 12 weeks: estradiol, -1.4 (95% CI, -1.6 to -1.2); moisturizer, -1.2 (95% CI, -1.4 to -1.0); and placebo, -1.3 (95% CI, -1.5 to -1.1). No significant differences were seen between estradiol (P = .25) or moisturizer (P = .31) compared with placebo. Mean total FSFI improvement was similar between estradiol (5.4; 95% CI, 4.0 to 6.9) and placebo (4.5; 95% CI, 2.8 to 6.1) (P = .64), and between moisturizer (3.1; 95% CI, 1.7 to 4.5) and placebo (P = .17). CONCLUSIONS AND RELEVANCE Our results suggest that neither prescribed vaginal estradiol tablet nor over-the-counter vaginal moisturizer provides additional benefit over placebo vaginal tablet and gel in reducing postmenopausal vulvovaginal symptoms. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02516202.
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Affiliation(s)
- Caroline M Mitchell
- Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Boston.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Susan D Reed
- Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Susan Diem
- Department of Medicine, University of Minnesota, Minneapolis.,Department of Epidemiology and Community Health, University of Minnesota, Minneapolis
| | | | | | - Kristine E Ensrud
- Department of Medicine, University of Minnesota, Minneapolis.,Department of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Andrea Z LaCroix
- Department of Family Medicine and Public Health, University of California at San Diego, La Jolla
| | - Bette Caan
- Division of Research, Kaiser Permanente of Northern California, Oakland, California
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The REJOICE trial: a phase 3 randomized, controlled trial evaluating the safety and efficacy of a novel vaginal estradiol soft-gel capsule for symptomatic vulvar and vaginal atrophy. Menopause 2018; 24:409-416. [PMID: 27922936 PMCID: PMC5367497 DOI: 10.1097/gme.0000000000000786] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Supplemental Digital Content is available in the text Objective: To evaluate the safety and efficacy of TX-004HR vaginal estradiol soft-gel capsules for moderate-to-severe dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Methods: In this randomized, double-blind, placebo-controlled, phase 3 study, postmenopausal women with a self-identified most bothersome symptom of dyspareunia received 4, 10, or 25 μg TX-004HR or placebo for 12 weeks. Four co-primary efficacy endpoints were change from baseline to week 12 in percentages of superficial and parabasal cells, vaginal pH, and severity of dyspareunia. Secondary endpoints included severity of vaginal dryness and vulvar and/or vaginal itching or irritation. Endometrial histology and adverse events (AEs) were included in the safety endpoints. Results: In all, 764 women were randomized (modified intent-to-treat population, n = 747; mean age 59 y). Compared with placebo, all three doses of TX-004HR significantly improved the four co-primary endpoints (P < 0.0001 for all, except dyspareunia with 4 μg, P = 0.0149). Changes in cytology, pH, and dyspareunia were also significant at weeks 2, 6, and 8. Vaginal dryness and vaginal itching/irritation improved. Sex hormone binding globulin concentrations did not change with treatment. TX-004HR was well-tolerated, with no clinically meaningful differences in treatment-emergent AEs versus placebo, and no treatment-related serious AEs or deaths. Conclusions: TX-004HR (4, 10, and 25 μg) was safe, well-tolerated, and effective for treating moderate-to-severe dyspareunia within 2 weeks with minimal systemic estrogen exposure. This novel product may be a potential new treatment option for women experiencing postmenopausal vulvar and vaginal atrophy.
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Chua Y, Limpaphayom KK, Cheng B, Ho CM, Sumapradja K, Altomare C, Huang K. Genitourinary syndrome of menopause in five Asian countries: results from the Pan-Asian REVIVE survey. Climacteric 2017; 20:367-373. [DOI: 10.1080/13697137.2017.1315091] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Y. Chua
- A Clinic For Women, Mt Alvernia Hospital, Singapore, Singapore
| | - K. K. Limpaphayom
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - B. Cheng
- Department of Obstetrics and Gynecology, Chiayi Chang Gung Memorial Hospital, Chiayi County, Taiwan
- Medical College, Chang Gung University, Taoyuan, Taiwan
| | - C. M. Ho
- Obstetrics and Gynecology, Pantai Hospital Cheras, Kuala Lumpur, Malaysia
| | - K. Sumapradja
- Department of Obstetrics and Gynecology, Dr Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | - K. Huang
- Department of Obstetrics and Gynecology, Chang Gung University and Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Most bothersome symptom in women with genitourinary syndrome of menopause as a moderator of treatment effects. Menopause 2016; 23:1092-101. [DOI: 10.1097/gme.0000000000000679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Quality of life and sexual function of naturally postmenopausal women on an ultralow-concentration estriol vaginal gel. Menopause 2016; 23:47-54. [PMID: 26079974 DOI: 10.1097/gme.0000000000000485] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This study aims to evaluate the sexual function and quality of life (QoL) of naturally postmenopausal women affected by genitourinary syndrome of menopause who were treated with an ultralow-concentration estriol vaginal gel (0.005%). METHODS Postmenopausal women with vulvovaginal atrophy symptoms and sexual disorders were enrolled in a case-control study. Women were treated with vaginal gel (containing 50 μg of estriol) daily for 3 weeks and then twice weekly up to 12 weeks. Determination of vaginal maturation index, evaluation of vaginal pH, and assessment of vaginal atrophy symptoms were carried out. QoL, sexual function, and distress were investigated using the Short Form 36, Female Sexual Function Index, and Female Sexual Distress Scale questionnaires. Changes between baseline and week 12 were assessed. RESULTS Sixty-eight women were included in the study group, and 42 women were included in the control group. Women on estriol vaginal gel had a significant increase in vaginal maturation index and improvement of vaginal pH compared with baseline (P < 0.05). Mean total Female Sexual Function Index score improved, and Female Sexual Distress Scale score decreased from baseline to follow-up. Results from the Short Form 36 questionnaire showed a significant improvement in the overall index of somatic aspects (P < 0.05). The control group showed no changes from baseline evaluation (P = NS). CONCLUSIONS Estriol vaginal gel (0.005%) therapy significantly improves the trophism of the vaginal mucosa and the sexual health and QoL of naturally postmenopausal women. These results confirm that low doses of vaginal estrogen must be considered as the first choice for the initial treatment of postmenopausal genitourinary symptoms.
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Parks DM, Levine J. Helping Women Understand Treatment Options for Vulvar and Vaginal Atrophy. Nurs Womens Health 2015; 19:298-312. [PMID: 26264795 DOI: 10.1111/1751-486x.12216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Vulvar and vaginal atrophy (VVA) is a common and progressive medical condition in postmenopausal women. The REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey assessed knowledge about VVA and its impact in 3,046 postmenopausal U.S. women, and recorded women's attitudes about their interactions with health care providers and about available treatments. REVIVE identified poor disease awareness and understanding among women, failure of health care professionals to evaluate women for VVA signs and symptoms, low treatment rates and concerns about the safety and efficacy of available therapies. Strategies to address these needs include proactive screening, education for women and clinicians about VVA and recommendations for treatment and follow-up.
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