Vaginal biological and sexual health – the unmet needs

Is There Still a Role for Sterilization by Tubal Ligation as a Contraceptive Method?

Tubal ligation has been used since the late nineteenth century to control undesired fertility in women. Over the years, there have been many improvements to the surgical technique, and the procedure has become a lot safer. Some recent developments, however, appear to make this procedure obsolete. In the first instance, there is now ample evidence that removing the Fallopian tubes rather than ligating them or closing them provides protection against developing ovarian carcinoma. The many surgical approaches and closure methods are therefore no longer appropriate. In the second instance, the use of long-acting reversible contraception has been shown to be as effective in preventing future pregnancy, more cost-effective and with even more health benefits than tubal ligation or tubectomy. This is especially true of the use of intrauterine levonorgestrel. The problem of regret and request for tubal ligation reversal, where that was performed, is eliminated as is the surgical concern of operating on older women with increased body mass index and medical co-morbidities.

Maintaining vulvar, vaginal and perineal health: Clinical considerations

Knowledge of female genital anatomy and physiology is often inadequate or incorrect among women. Precise patient-physician conversations can be inhibited by a reluctance or inability to speak accurately about the vulva and vagina, with the terms often being used interchangeably. There is a paucity of scientific evidence and clinical guidelines to support women and physicians in ensuring best practices in feminine hygiene. In this review, the unmet needs in the field are highlighted. Evidence is provided for the complex array of physiological and pathological systems, mechanisms and behaviours that either protect or, if inappropriate, predispose the vulva and vagina to infections, irritation or other conditions. The need for attention to perineal health is recommended, given the interdependence of perineal and vulvar microbiota and the risk of colonic pathogens reaching the vulva and the vagina. Differences in feminine hygiene practices can vary widely across the world and among varying age groups, and suboptimal habits (such as vaginal douching or the use of certain cleansers) can be associated with increased risks of vulvar and vaginal conditions. Critical areas for discussion when advising women on their intimate health include: advice surrounding aesthetic vulvar cosmetic trends (such as depilation and genital cosmetic surgery), bowel health and habits, and protection against sexually transmitted infections. Routine, once-daily (maximum twice-daily) washing of the vulva with a pH-balanced, mild cleanser is optimal, ideally soon after bowel voiding, when feasible. Due to the finely balanced ecosystems of the vulva, the vagina and the perineal area, a scientific and clinical perspective is essential when determining the most appropriate vulvar cleansers based on their components. Correct intimate care may contribute to improved genital and sexual health and overall well-being. An increased awareness of correct practices will empower women to be the advocates of their own intimate health.

The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women

BACKGROUND

Vulvo-Vaginal Atrophy (VVA) affects about fifty percent of postmenopausal women, contributing more vulnerable sexual and psycho-relational equilibrium. To date, no psychometric instruments have been designed to assess the impact of coital pain associated with VVA on sexual quality of life.

AIM

To validate a new psychometric tool, the Gynogram, able to investigate coital pain and to quantify its impact on sexual well-being in menopause.

METHODS

214 sexually active postmenopausal women were enrolled in the study during clinical consultations in gynecological outpatient clinics in Italy. After gynecological examination and evaluation of the presence of VVA, the study sample was divided in a clinical group (103 women with certified diagnosis of VVA) and in a control group (111 women without certified diagnosis of VVA) according to the Vaginal Health Index (VHI) cut-off. Factor, Reliability and Receiving Operating Characteristics (ROC) analysis were performed in order to validate our newly created Gynogram.

OUTCOMES

A structured questionnaire, named Gynogram, to assess coital pain and its impact, and the Female Sexual Function Index (FSFI).

RESULTS

The factor analysis performed on the original form (80 items) reduced the Gynogram to 24 items. Reliability analysis conducted with Cronbach's Alpha coefficients showed high values in all the components (ranging from .813 to .972), both in the long and in the short form. The sensitivity analysis demonstrated that the Gynogram, with a cut-off ≤93, is able to recognize a clinically significant coital pain. With respect to the FSFI, statistically significant differences were found for all the domains. In addition, statistically significant differences were found for all the twelve factors of the Gynogram, showing that VVA profoundly affects the sexual quality of life of women in post-menopause.

CLINICAL TRANSLATION

The utility of this tool consists in the possibility to improve prognosis, compliance/adherence and treatment outcomes.

STRENGTHS AND LIMITATIONS

The Gynogram is able to evaluate and to quantify the impact of coital pain associated with VVA. Moreover, it can also recognize the areas of biopsychosocial functioning being more affected by this clinical condition. The main limit of the study is the impossibility to evaluate both mental health and partner's general and sexual health.

CONCLUSIONS

The Gynogram is a new and validated psychometric tool able to detect the impact of symptomatic VVA on sexual quality of life among post-menopausal women, with a specific focus on the different areas of sexual functioning. Nappi RE, Graziottin A, Mollaioli A, et al. The Gynogram: A Multicentric Validation of a New Psychometric Tool to Assess Coital Pain Associated With VVA and Its Impact on Sexual Quality of Life in Menopausal Women. J Sex Med 2021;18:955-965.

Modern management of genitourinary syndrome of menopause

The genitourinary syndrome of menopause (GSM) is the accepted term used to describe the broad spectrum of genitourinary tract symptoms and signs caused by the loss of endogenous sex steroids that occurs at the time of and after the menopause. Global improvements in healthcare have resulted in an ageing population. Today, women are spending 40% of their lives in the postmenopausal state, and with 50–70% of postmenopausal women reporting symptomatic GSM, safe and efficacious treatments are needed for this troublesome condition. This article reviews current evidence for non-pharmacological and pharmacological treatments with a focus on novel and minimally invasive procedures such as energy-based devices (CO₂ laser, YAG laser), hyaluronic acid, dehydroepiandrosterone, and selective oestrogen receptor modulators.

An individualized approach to the management of vaginal atrophy in Latin America

OBJECTIVE

In the absence of guidelines specific for Latin America, a region where the impact of menopause is becoming increasingly important, an evidence-based specialist opinion on management of vaginal atrophy will help improve outcomes.

METHODS

An advisory board meeting was convened in São Paulo, Brazil, to discuss practical recommendations for managing vaginal atrophy in women in Latin America. Before the meeting, physicians considered various aspects of the condition, summarizing information accordingly. This information was discussed during the meeting. The expert consensus is now summarized.

RESULTS

In Latin America, given the relatively early age of menopause, it will be beneficial to raise awareness of vaginal atrophy among women before they enter menopause, considering cultural attitudes and involving partners as appropriate. Women should be advised about lifestyle modifications, including attention to genital hygiene, clothing, and sexual activity, and encouraged to seek help as soon as they experience vaginal discomfort. Although treatment can be started at any time, prompt treatment is preferable. A range of treatments is available. By addressing the underlying pathology, local estrogen therapy can provide effective symptom relief, with choice of preparation guided by patient preference. An individualized treatment approach should be considered, giving attention to patients' specific situations.

CONCLUSIONS

It is critical that women are empowered to understand vaginal atrophy. Educating women and healthcare providers to engage in open dialogue will facilitate appreciation of the benefits and means of maintaining urogenital health, helping to improve outcomes in middle age and beyond. Women should receive this education before menopause.

Therapies for the management of genitourinary syndrome of menopause

Introduction

The genitourinary syndrome of menopause 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).

Methods

We conducted a systematic scoping review of data in women therapies with genitourinary syndrome of menopause or vulvovaginal atrophy in peer-reviewed, English-language publications in the last 20 years.

Results

The terms vulvovaginal atrophy and atrophic vaginitis, which were generally used up 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 sex steroid level in menopause. The concept of genitourinary syndrome of menopause was recently introduced and has been gaining widespread use. Since genitourinary syndrome of menopause may have a profound negative impact on the quality of life of postmenopausal women, patients should be made aware of these problems and treated with an appropriate effective therapy. Therefore, in this review we introduce therapies for this syndrome, both local and systemic, and discuss the importance of genitourinary syndrome of menopause comprehension and the need to have an active treatment of this syndrome in postmenopausal women.

Conclusion

The increasing number of therapies for menopausal symptoms opens up new options. In addition, new products have been designed and developed by pharmaceutical companies as new possibilities for patients who did not have any treatment available and also to improve compliance.