Vulvar and vaginal atrophy (VVA) is a chronic medical condition experienced by many postmenopausal women. Symptoms include dyspareunia (pain with intercourse), vaginal dryness, and irritation and may ...affect sexual activities, relationships, and activities of daily life.
The aim of this study is to characterize postmenopausal women's experience with and perception of VVA symptoms, interactions with healthcare professionals (HCPs), and available treatment options.
An online survey was conducted in the United States in women from KnowledgePanel®, a 56,000‐member probability‐selected Internet panel projectable to the overall US population. Altogether, 3,046 postmenopausal women with VVA symptoms (the largest US cohort of recent surveys) responded to questions about their knowledge of VVA, impact of symptoms on their activities, communication with HCPs, and use of available treatments.
Percent is calculated as the ratio of response over total responding for each question for all and stratified participants.
The most common VVA symptoms were dryness (55% of participants), dyspareunia (44%), and irritation (37%). VVA symptoms affected enjoyment of sex in 59% of participants. Additionally, interference with sleep, general enjoyment of life, and temperament were reported by 24%, 23%, and 23% of participants, respectively. Few women attributed symptoms to menopause (24%) or hormonal changes (12%). Of all participants, 56% had ever discussed VVA symptoms with an HCP and 40% currently used VVA‐specific topical treatments (vaginal over‐the‐counter OTC products 29% and vaginal prescription therapies 11%). Of those who had discussed symptoms with an HCP, 62% used OTC products. Insufficient symptom relief and inconvenience were cited as major limitations of OTC products and concerns about side effects and cancer risk limited use of topical vaginal prescription therapies.
VVA symptoms are common in postmenopausal women. Significant barriers to treatment include lack of knowledge about VVA, reluctance to discuss symptoms with HCPs, safety concerns, inconvenience, and inadequate symptom relief from available treatments. Kingsberg SA, Wysocki S, Magnus L, and Krychman ML. Vulvar and vaginal atrophy in postmenopausal women: Findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013;10:1790–1799.
Vulvar and vaginal atrophy (VVA) affects up to two thirds of postmenopausal women, but most symptomatic women do not receive prescription therapy.
To evaluate postmenopausal women's perceptions of ...VVA and treatment options for symptoms in the Women's EMPOWER survey.
The Rose Research firm conducted an internet survey of female consumers provided by Lightspeed Global Market Insite. Women at least 45 years of age who reported symptoms of VVA and residing in the United States were recruited.
Survey results were compiled and analyzed by all women and by treatment subgroups.
Respondents (N = 1,858) had a median age of 58 years (range = 45–90). Only 7% currently used prescribed VVA therapies (local estrogen therapies or oral selective estrogen receptor modulators), whereas 18% were former users of prescribed VVA therapies, 25% used over-the-counter treatments, and 50% had never used any treatment. Many women (81%) were not aware of VVA or that it is a medical condition. Most never users (72%) had never discussed their symptoms with a health care professional (HCP). The main reason for women not to discuss their symptoms with an HCP was that they believed that VVA was just a natural part of aging and something to live with. When women spoke to an HCP about their symptoms, most (85%) initiated the discussion. Preferred sources of information were written material from the HCP's office (46%) or questionnaires to fill out before seeing the HCP (41%).The most negative attributes of hormonal products were perceived risk of systemic absorption, messiness of local creams, and the need to reuse an applicator. Overall, HCPs only recommended vaginal estrogen therapy to 23% and oral hormone therapies to 18% of women. When using vaginal estrogen therapy, less than half of women adhered to and complied with posology; only 33% to 51% of women were very to extremely satisfied with their efficacy.
The Women's EMPOWER survey showed that VVA continues to be an under-recognized and under-treated condition, despite recent educational initiatives. A disconnect in education, communication, and information between HCPs and their menopausal patients remains prevalent.
Kingsberg S, Krychman M, Graham S, et al. The Women's EMPOWER Survey: Identifying Women's Perceptions on Vulvar and Vaginal Atrophy and Its Treatment. J Sex Med 2017;14:413–424.
Abstract
This Position Statement has been endorsed by the International Menopause Society, The Endocrine Society, The European Menopause and Andropause Society, The International Society for Sexual ...Medicine, The International Society for the Study of Women's Sexual Health, The North American Menopause Society, The Federacion Latinoamericana de Sociedades de Climaterio y Menopausia, The Royal College of Obstetricians and Gynecologists, The International Society of Endocrinology, The Endocrine Society of Australia, and The Royal Australian and New Zealand College of Obstetricians and Gynecologists.*
The only evidence-based indication for testosterone for women is for HSDD. There are insufficient data for using testosterone for any other symptom/condition or for disease prevention.
Low or absent sexual desire is the most common sexual dysfunction in women, and its prevalence peaks during midlife. Its etiology is complex and may include biologic, psychologic, and social ...elements. Major risk factors for its development include poor health status, depression, certain medications, dissatisfaction with partner relationship, and history of physical abuse, sexual abuse, or both. Diagnosis is based on criteria set by the Diagnostic and Statistical Manual of Mental Disorders (5th Edition) and requires that a woman experience personal distress. Clinical evaluation should include medical history, sexual history, and, sometimes, a physical examination. Laboratory data are of limited value, except when warranted by history or physical examination. Treatment options include nonpharmacologic interventions such as education, office-based counseling, and psychotherapy. Although there are no U.S. Food and Drug Administration (FDA)–approved treatments for low desire, pharmacologic agents have been used off-label for this purpose. Bupropion is an antidepressant that has been shown to improve desire in some women with and without depression. Systemic estrogen therapy is not recommended in the absence of vasomotor symptoms and is not directly associated with desire. However, vaginal estrogen is useful in patients presenting with concomitant vaginal atrophy and dyspareunia. Ospemifene is a selective estrogen receptor modulator that can be used as an alternative to vaginal estrogen. Exogenous testosterone has demonstrated efficacy in treating loss of desire in postmenopausal women. However, patients should be counseled that it is not FDA-approved for this purpose and there are limited published long-term safety data. Several agents for the treatment of low desire are currently in development. Gynecologists are in a unique position to address concerns about sexual desire in women.
Clinical Effects of Early or Surgical Menopause Kingsberg, Sheryl A; Larkin, Lisa C; Liu, James H
Obstetrics and gynecology (New York. 1953),
2020-April, 2020-04-00, 20200401, Volume:
135, Issue:
4
Journal Article
Peer reviewed
Increasing numbers of women experience early menopause due in part to surgical treatment for benign gynecologic disorders and the rise in risk-reducing bilateral salpingo-oophorectomy in women with ...BRCA mutations. Unfortunately, the adverse health consequences of early loss of ovarian function accelerate the menopausal state and affect multiple systems, including cardiovascular, neurologic, bone, and connective tissue, and affect quality of life owing to vasomotor symptoms, mood, sleep, and sexual function. Yet many clinicians and women remain reluctant to use hormone therapy because of the Womenʼs Health Initiativeʼs adverse findings, even though they are not applicable to women with early menopause. This review examines the effects of early menopause and highlights the critical role of hormone therapy in this population.
Survey data provide evidence that low sexual desire is commonly reported among pre- and postmenopausal women. About 10% of women with low sexual desire experience related personal distress. This ...survey assessed women's attitudes toward the condition and how it affects personal relationships, along with level of awareness of low sexual desire as a medical condition and treatment-seeking history.
The online survey was conducted in a convenience sample of 450 pre- and postmenopausal women aged 20 to 60 years with self-described low sexual desire and related distress. The percentage reported is the ratio of responses over number of respondents for each point on visual analogy scales or option(s) on multiple-choice questions.
Twenty-seven percent of premenopausal and 34% of postmenopausal women were very dissatisfied with their current sexual desire level. Over 70% attributed personal and interpersonal difficulties to low sexual desire, most often negative impacts on body image and self-confidence. Feeling "less connectedness" was the most frequently selected impact on partner relationships. Approximately 90% of respondents would like to have or desire sex more often; 95% believed that one or two more satisfying sexual experiences per month would be meaningful. Most respondents did not realize that distressing low sexual desire was a treatable medical condition and had never mentioned their low sexual desire to health care providers.
Despite reporting negative impacts of low sexual desire and a desire for more frequent sex, most women had not sought medical help. These results add to the evolving recognition of the importance of sexual functioning in women's lives.
Postmenopausal women's knowledge about vulvar and vaginal atrophy (VVA) and available treatment options has historically been inadequate. Recent direct-to-consumer marketing and educational efforts ...would have been expected to increase awareness and treatment options.
To compare results of the Women's EMPOWER survey with other available VVA surveys to assess progress in women's understanding and approaches to treatment of VVA.
The Women's EMPOWER survey, an internet-based survey of US women with VVA symptoms, assessed women's awareness of VVA and their behaviors and attitudes associated with symptom treatment.
These survey results were compared with previously published results of the Revealing Vaginal Effects at Mid-Life (REVEAL), Women's Voices in Menopause (WVM), Vaginal Health: Insight, Views, & Attitudes (VIVA), Clarifying Vaginal Atrophy's Impact on Sex and Relationship (CLOSER), and Real Women's Views of Treatment Options for Menopausal Vaginal Changes (REVIVE) surveys.
Results of the Women's EMPOWER survey were consistent with those of past VVA surveys and showed that postmenopausal women generally failed to recognize VVA and its chronic, progressive process and that they were reluctant to discuss vaginal or sexual symptoms with their health care professionals (HCPs). However, women indicated a strong desire for accurate medical information about VVA from their health care professionals and a willingness to learn if HCPs would initiate the conversation. Most women believed that vaginal symptoms are a normal part of aging and they just need to cope with the symptoms. In the United States, women were most concerned with safety-related issues, including increased risk of breast cancer, side effects, and systemic absorption.
The Women's EMPOWER survey demonstrates and reinforces that even with multimedia marketing and educational strategies in the years after other major VVA surveys, minimal progress has been made toward increasing women's awareness of, knowledge about, or understanding of VVA. Based on these data, a focus on initiating discussions and education with postmenopausal women so that they better comprehend VVA as a chronic progressive medical condition (not just aging), the symptoms associated with VVA, and the benefit-risk profile regarding treatment options is warranted.
Krychman M, Graham S, Bernick B, et al. The Women's EMPOWER Survey: Women's Knowledge and Awareness of Treatment Options for Vulvar and Vaginal Atrophy Remains Inadequate. J Sex Med 2017;14:425–433.
OBJECTIVE:To evaluate the safety and efficacy of bremelanotide for the treatment of premenopausal women with hypoactive sexual desire disorder.
METHODS:Two identical phase 3, randomized, ...double-blind, placebo-controlled, multicenter clinical trials (RECONNECT) evaluated the safety and efficacy of bremelanotide 1.75 mg administered subcutaneously as needed in premenopausal women with hypoactive sexual desire disorder. Patients were randomized 1:1 to 24 weeks of treatment with bremelanotide or placebo. Sample size was estimated based on simulations from key endpoints in patients with hypoactive sexual desire disorder from a prior trial. Coprimary efficacy endpoints were change from baseline to end-of-study in the Female Sexual Function Index–desire domain score and Female Sexual Distress Scale–Desire/Arousal/Orgasm item 13.
RESULTS:Study 301 began on January 7, 2015, and concluded on July 26, 2016. Study 302 began on January 28, 2015, and concluded on August 4, 2016. Of the 1,267 women randomized, 1,247 and 1,202 were in the safety and efficacy (modified intent-to-treat) populations, respectively. Most participants were white (85.6%), from U.S. sites (96.6%), and had a mean age of 39 years. From baseline to end-of-study, women taking bremelanotide had statistically significant increases in sexual desire (study 3010.30, P<.001; study 3020.42, P<.001; integrated studies 0.35, P<.001) and statistically significant reductions in distress related to low sexual desire (study 301−0.37, P<.001; study 302−0.29, P=.005; integrated studies −0.33, P<.001) compared with placebo. Patients taking bremelanotide experienced more nausea, flushing, and headache (10% or more in both studies) compared with placebo.
CONCLUSIONS:Both studies demonstrated that bremelanotide significantly improved sexual desire and related distress in premenopausal women with hypoactive sexual desire disorder. The safety profile was favorable. Most treatment-emergent adverse events were related to tolerability and the majority were mild or moderate in intensity.
CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT02333071 (study 301) and NCT02338960 (study 302).
FUNDING SOURCE:Palatin Technologies, Inc., and AMAG Pharmaceuticals, Inc.
How a woman responds to sexual cues is highly dependent on a number of distinct, yet related, factors. Researchers have attempted to explain the female sexual response for decades, but no single ...model reigns supreme. Proper female sexual function relies on the interplay of somatic, psychosocial and neurobiological factors; misregulation of any of these components could result in sexual dysfunction. The most common sexual dysfunction disorder is hypoactive sexual desire disorder (HSDD). HSDD is a disorder affecting women across the world; a recent in-person diagnostic interview study conducted in the USA found that an estimated 7.4% of US women suffer from HSDD. Despite the disorder's prevalence, it is often overlooked as a formal diagnosis. In a survey of primary care physicians and obstetrics/gynaecology specialists, the number one reason for not assigning an HSDD diagnosis was the lack of a safe and effective therapy approved by the US Food and Drug Administration (FDA). This changed with the recent FDA approval of flibanserin (Addyi™) for the treatment of premenopausal women with acquired, generalized HSDD; there are still, however, no treatments approved outside the USA. HSDD is characterized by a marked decrease in sexual desire, an absence of motivation (also known as avolition) to engage in sexual activity, and the condition's hallmark symptom, marked patient distress. Research suggests that HSDD may arise from an imbalance of the excitatory and inhibitory neurobiological pathways that regulate the mammalian sexual response; top-down inhibition from the prefrontal cortex may be hyperactive, and/or bottom-up excitation to the limbic system may be hypoactive. Key neuromodulators for the excitatory pathways include norepinephrine, oxytocin, dopamine and melanocortins. Serotonin, opioids and endocannabinoids serve as key neuromodulators for the inhibitory pathways. Evolving treatment strategies have relied heavily on these crucial research findings, as many of the agents currently being investigated as treatment options for HSDD target and influence key players within these excitatory and inhibitory pathways, including various hormone therapies and centrally acting drugs, such as buspirone, bupropion and bremelanotide.
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