Top News in Internal Medicine April 05 2019 (10 of 10) - MD Linx


Treatment of vulvovaginal atrophy (VVA) in postmenopausal women should start as early as possible and continue as long as required, researchers say.

"It is important that we encourage women to report their VVA symptoms early to their health-care professionals. This must not be regarded by the health-care profession, society, and the media as a taboo subject," Dr. Nick Panay of Imperial College London told Reuters Health.

"It is [also] important that health-care professionals engage their menopause patients in conversations regarding VVA in a professional and sensitive manner," he said by email. "If they don't ask the correct questions, the information may not be volunteered by the patient."

"If therapy is delayed for too long, VVA changes can become less reversible or irreversible, regardless of the type of therapy used," he added. That said, he noted, "It is always worth attempting treatment of VVA, even if the condition is long standing, because some benefits may still be achieved."

Dr. Panay and colleagues surveyed 1,242 postmenopausal women with untreated VVA and 918 who were treated. The median age was about 50. All completed the EuroQoL questionnaire (EQ5D3L), the Day-to-Day Impact of Vaginal Aging (DIVA), the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale - revised (FSDS-R).

As reported online March 18 in Maturitas, baseline symptoms for both groups included vaginal dryness inside and outside; pain inside; pain during intercourse and exercise; bleeding during intercourse or sexual contact; and burning, itching, or irritation. About 37% of women in both groups had urinary incontinence.

The most common treatment was non-hormonal therapy applied vaginally (31.8%), followed by hormonal therapy applied vaginally (11.6%), and systemic hormonal therapy (4.7%).

Women on VVA treatment presented with more and worse symptoms. The authors suggest, "The most plausible interpretation...might be that women only seek or commence treatment when symptoms have already become so distressing they cannot tolerate them any longer."

Compared with untreated women, sexual function was higher in those who were treated (FSFI: 16.7 vs 15.6), as was the sexual distress score (FSDS-R: 12.3 vs 9.2). Similarly, the DIVA score was significantly worse overall for treated vs untreated women in three of the four dimensions: emotional well-being, sexual functioning, and self-concept and body image.

Women treated with systemic hormones had fewer VVA symptoms, lower vaginal impact (DIVA), and better sexual function (FSFI and FSDS-R) and vaginal health. Treatment duration had no impact on the findings.

"It is likely that the women on systemic therapy had less severe symptoms because (therapy) had been initiated early in the menopause transition to treat hot flushes and sweats, before VVA symptoms had become severe," Dr. Panay noted. "Whether the therapy is local or systemic, the key point is that it should be started early in order to be most effective and avoid needless suffering," he concluded.

Dr. Sherry Ross, a women's health expert at Providence Saint John's Health Center in Santa Monica, CA, said she "completely agrees" with the study findings. "Women experiencing VVA often agonize in silence for many years," she told Reuters Health by email. "Hot flashes may improve over time, but VVA only worsens with time."

"With menopause and the loss of estrogen stimulation in the vagina, the tissue becomes dry and pale," she said. "The labia can become fused and the vagina and clitoris shrink. As a result, intercourse and other forms of vaginal contact become painful, if not impossible."

"The doctor must guide the patient," she said. "I tell my patients the bottom line is that quality of life, especially in the bedroom, is incredibly important and should be a priority. Expect the unexpected as your vulva and vagina transition from perimenopause to menopause...Communicate openly with your partner so they know what you are going through. The aging vagina does not have to ruin a sexual relationship."

Sponsorship and article processing charges were funded by Shionogi. One author is an employee and Dr. Panay and other authors receive funds fees from the company.

—Marilynn Larkin

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