Vaginal Atrophy Undertreated, Has Adverse Effect on Relationships

Fran Lowry

October 09, 2012

October 9, 2012 (Orlando, Florida) — Postmenopausal women have higher rates of vaginal atrophy in the United States than in other countries, in large part because they refuse to consider remedies such as local estrogen therapy, according to a survey presented here at the North American Menopause Society (NAMS) 23rd Annual Meeting.

Dr. James Simon

Because sex becomes painful as a result, the women and their partners avoid it. This can destroy intimacy, have an adverse effect on emotional and physical health, and even ruin relationships, James A. Simon, MD, clinical professor of obstetrics and gynecology at the George Washington University School of Medicine in Washington, DC, and past president of NAMS, told Medscape Medical News.

Nobody in the United States wants to talk about "old ladies' vaginas," Dr. Simon said.

"This survey shows that less than half of menopausal women with vaginal dryness, pain with intercourse, or bleeding after sex are actually being treated.... We need to raise awareness and bring genital health into the conversation in the same way that erectile dysfunction was brought to the fore by Senator Dole, who made himself an example and a spokesperson for a very private thing," he said. "We need a well-respected, visible, menopausal woman to bring this to the masses, because now we have survey data that say it's not only prevalent, it's not being adequately treated and it's affecting relationships."

Dr. Simon presented data from an international survey of 4167 cohabiting or married postmenopausal women 55 to 65 years of age with vaginal discomfort and 4174 of their aged-matched male partners from 9 countries: Canada, Denmark, Finland, France, Italy, Norway, Sweden, the United Kingdom, and the United States.

The survey was designed to assess the impact of vaginal atrophy and its treatment on emotional and physical relationships between postmenopausal women and their partners and to compare the insights, views, and attitudes in the United States with those in other countries.

In the online survey, participants were asked about the impact of vaginal atrophy and hormone therapy on intimacy, relationships, and self-esteem; the symptoms and impact of menopause, compared with their expectations; the willingness to discuss vaginal atrophy or erectile dysfunction with a partner or healthcare provider; and sources of information and advice.

Vaginal discomfort or atrophy symptoms include dryness, itching, burning, or soreness in the vagina, bleeding during intercourse, pain during intercourse, pain during urination, and pain in the vagina in connection with touching.

In their analysis of the data, Dr. Simon and colleagues focused on the 501 women and 509 men in the United States who were married.

Of all survey respondents, American women in were the least likely to use local vaginal estrogen treatment, "in spite of the fact that we have a high level of education, a high level of access to medical care, and coverage by most insurance plans for drugs in this category," Dr. Simon said. "My conclusion is that women in this country fear estrogen more than elsewhere, so they won't use it," he said, adding that the fear is unjustified.

American women were the most likely (77%) to use lubricating gels and creams, but only 31% used hormone therapy, including local estrogen therapy, to relieve their symptoms.

"Lubricating gels and creams are somewhat effective, but they do not treat vaginal atrophy," Dr. Simon pointed out.

Of the women who used local estrogen therapy, 56% reported that sex was less painful, as did 57% of their male partners. Almost 40% reported that sex was more satisfying for themselves and their partners.

The survey also found that 65% of the men felt guilty about having sex when they thought or knew that it was going to hurt their partner. "I thought that was fascinating, and it is important to have actual data for that," Dr. Simon noted.

The analysis of the American respondents by Dr. Simon and colleagues revealed other key findings:

  • most women (71%) and men (77%) were willing to discuss vaginal discomfort with their partners, but 22% of the women were uncomfortable with this discussion and 13% of the men said they didn't want to know

  • because of vaginal discomfort, 57% of the women avoided being intimate, 30% found sex less satisfying, and 24% thought that sex was less satisfying for their partners

  • 64% of women reported that sex was painful

  • 65% of women reported a loss of libido

  • 28% of women felt less attractive

  • 31% of women stopped having sex altogether

  • 35% of women no longer felt sexually attractive because of vaginal discomfort

  • 24% felt emotionally distant from their partner

  • 39% of men and women thought the effect of menopause on their physical relationship was worse than they had expected.

Emphasizing Genital Health

"These are findings that bring the importance of sex in a relationship to the forefront and emphasize the importance of proper postmenopausal genital health," Dr. Simon said.

Vulvar and vaginal atrophy symptoms tend to peak at about 57 to 60 years of age, or about 5 to 6 years after the last menstrual period. "It's easier to fix something if it hasn't been broken too long, so it's typically easier to prevent serious atrophy by starting [estrogen therapy] early. It is possible to treat severe atrophy in older women; it's just a bigger hurdle," he said.

"Relationships go bad for a whole bunch of reasons, but why not take vaginal atrophy out of the equation," Dr. Simon said.

Women Suffering in Silence

Dr. JoAnn Pinkerton

The question about menopausal vaginal dryness is one that does not get asked in the healthcare provider's office, but it should, JoAnn Pinkerton, MD, director of a large midlife health center, professor of obstetrics and gynecology at the University of Virginia in Charlottesville, and past president of NAMS, told Medscape Medical News.

"This doesn't get asked in the provider's office because if you ask the question, you need to be able to offer suggestions, and it is somewhat complex," Dr. Pinkerton said.

"Although the initial changes are around vaginal dryness, vaginal atrophy, and pain with sex, there is also the issue of libido.... Even if you make it less uncomfortable to have sex, you also have to address the desire aspect, and we don't currently have an FDA-approved treatment for that," she said.

"What we have found is that women who use local vaginal estrogen do have an ability to have sex, which improves their sex life as well as their intimacy. The NAMS 2012 position statement says that if vaginal dryness is just a local problem, you should use local therapy," Dr. Pinkerton explained.

Women can use over-the-counter products like lubricants or moisturizers. "They help [but] don't actually reverse the menopausal changes because you lose the superficial cells, you lose the pH, and the opening into the vagina actually shrinks," she said. "Women get a spasm in the muscle, which makes it worse, so you have to not only replace the estrogen, you have to also work with women to get the vagina to become functional again," she noted.

"This survey highlights the fact that this is a major issue for women and men — for their marriage and for their intimacy," Dr. Pinkerton said. "It is something that we as providers need to address.... We have to get providers to ask the question and women to raise the problem, and then we have to begin to work on a solution."

This study was sponsored by Novo Nordisk, the makers of estradiol vaginal tablets (Vagifem). Dr. Simon reports financial relationships with Abbott Laboratories, Agile Therapeutics, Amgen, Ascend Therapeutics, Azur Pharmaceuticals, Bayer, BioSante Pharmaceuticals, Boehringer-Ingelheim Pharmaceuticals, Depomed, Endoceutics, Fabre-Kramer Pharmaceuticals, Laboratoire HRA Pharma, Meditrina Pharmaceuticals, Merck, Merrion Pharmaceuticals, NDA Partners, Novartis Pharmaceuticals Corporation, Novo NordMerck, Noven, Novogyne, Pfizer, Palatin Technologies, Pfizer, Shionogi, Slate Pharmaceuticals, Sprout Pharmaceuticals, Teva Women's Health, Trovis Pharmaceuticals LLC, Warner Chilcott, and Watson Pharmaceuticals. Dr. Pinkerton reports financial relationships with Depomed, Merck, Novogyne, Pfizer, Shionogi, BioNova, Bionovo, and Endoceutics.

North American Menopause Society (NAMS) 23rd Annual Meeting: Abstract S-17. Presented October 5, 2012.