After menopause, vulvovaginal troubles are common and linked with other pelvic problems

The researchers from Dartmouth, Yale, and the Connecticut Healthcare System recruited 358 women ages 55 and older from primary care offices and senior centers to answer questions about common symptoms after menopause. The women answered questionnaires, not only about symptoms such as vaginal and vulvar dryness and irritation and their impact, but also about other menopause symptoms, other pelvic problems such as urinary urgency and urinary and fecal incontinence, whether they had seen a gynecologist, and what sort of treatment they had received.

Vulvar and vaginal symptoms--itching, burning, stinging, pain, irritation, dryness, discharge, or odor--were very common. A little more than half of the women (51%) said they had one or more of these. The symptoms also had a significant impact on their lives. Forty percent of the women with symptoms said the symptoms posed emotional problems, and 33% said they had an impact on their lifestyle. More than three-quarters of the women who were sexually active with a partner (76%) said the symptoms posed problems in their sex lives.

But with these symptoms came others. Many women with the vulvar and vaginal symptoms also had urinary frequency (50%) or leaking because of urinary urgency (43%). That helps confirm why NAMS and other organizations gave these postmenopausal problems a new name that includes urinary symptoms--"genitourinary syndrome of menopause" or GSM. In addition to urinary problems, significantly more women with the vulvovaginal symptoms than without also had pelvic organ prolapse or fecal incontinence without diarrhea. The women with the vulvar and vaginal symptoms also tended to have more menopausal symptoms other than hot flashes.

But, despite all these symptoms and the distress they cause, nearly a third of the women with symptoms (33%) had not seen a gynecologist in the last two years. And a huge majority--83%--were not getting the standard GSM treatment, which is low-dose estrogen in the vagina through creams, pills, or rings.

"This study demonstrates that there is an unmet need for postmenopausal women to have regular gynecologic visits where questions can be asked about vaginal and urinary health problems and assessment can be made to determine the presence of vulvovaginal atrophy, urinary symptoms of urgency or incontinence or pelvic floor disorders and offer FDA approved safe and effective therapies," says NAMS Executive Director JoAnn V. Pinkerton, MD, NCMP "Women need to tell their healthcare providers about their genitourinary symptoms, and providers need to ask."

The boxed warnings on the low-dose intravaginal estrogen therapies for GSM (also known as vulvovaginal atrophy or VVA) may have made providers reluctant to prescribe them and women to use them.

"The boxed warnings prompt a level of fear that is out of step with these low-dose, local estrogen products," said Dr. Pinkerton. That prompted experts from NAMS and leaders from other scientific organizations to go to FDA recently to request removing this warning from the label information. The NAMS experts who spoke to FDA stressed that providers should exercise caution and evaluate the uterus if women develop bleeding as well as advising women to discuss the use of low-dose intravaginal estrogen with their oncologist if they have had cancer.

"Diagnosis of these problems requires a pelvic exam and evaluation of the vaginal and vulvar tissues to look for atrophy, prolapse, or infection, noted Dr. Pinkerton. Safe and effective therapies are available and include, not only the first-line, low-dose vaginal estrogen creams, tablets, or rings, but also ospemiphene, the new oral selective estrogen receptor modulator or SERM that treats painful intercourse."