Vulvovaginal Symptoms Prevalence in Postmenopausal Women and Relationship to Other Menopausal Symptoms and Pelvic Floor Disorders

Elisabeth A. Erekson, MD, MPH; Fang-Yong Li, MPH; Deanna K. Martin, MPH; Terri R. Fried, MD


Menopause. 2016;23(4):368-375. 

In This Article

Abstract and Introduction


Objective. The primary objective of this study was to use the Vulvovaginal Symptom Questionnaire (VSQ) to estimate the prevalence and examine the emotional, lifestyle, and sexual impact of vulvovaginal symptoms in postmenopausal women.

Methods. We administered the VSQ, a previous validated instrument to 358 postmenopausal women recruited from primary care physician offices and local senior centers. The first seven questions of the VSQ comprise the symptom subscale (itching, burning, hurting, irritation, dryness, discharge, and odor). Women who answered "Yes" to any of the first seven symptom questions were considered to have vulvovaginal symptoms.

Results. Two hundred seventy-nine women were recruited from primary care offices and 79 women were recruited from senior centers. One hundred eighty-three postmenopausal women (51.1%; 95% CI 45.9%, 56.3%) reported at least one vulvovaginal symptom. The most common symptom was being dry 35.8% (n/N=128/358). Ten percent of women (n/N=38/358) reported five or more symptoms and 6% of women reported all seven symptoms in the last week. For women reporting one or more vulvovaginal symptoms, 40.4% (n/N=74/183) reported emotional impact (Yes to ≥1 out of 4 emotional impact subscale items) and 32.8% (n/N=60/183) reported lifestyle impact (Yes to ≥1 out of 5 lifestyle impact subscale items) from these symptoms. For sexually active women reporting vulvovaginal symptoms, 75.3% (n/N=67/89) reported sexual impact (Yes to ≥1 out of 4 sexual impact subscale items). Vulvovaginal symptoms were associated with increased co-occurrence of specific pelvic floor disorders, including pelvic organ prolapse (P=0.001), anal incontinence to solid stool (P=0.001), urinary frequency (P=0.02), urgency urinary incontinence (P=0.001), and dysuria (P<0.001).

Conclusions. Vulvovaginal symptoms are common and present in over 50% of postmenopausal women. Sizeable proportions of women with vulvovaginal symptoms report emotional, lifestyle, and sexual impact from these symptoms.


Genitourinary syndrome of menopause (GSM) is a new terminology for vulvovaginal atrophy (VVA) formally approved by the International Society for the Study of Women's Sexual Health and The North American Menopause Society in 2014.[1] VVA includes physical signs of decreased estrogen, symptoms of dryness, burning, irritation, lack of lubrication, discomfort, and pain. This new terminology was proposed because the term atrophy has an unnecessary negative connotation in describing a normal aging process and the unacceptability of the term vagina for use in the media. GSM also encompasses urogenital/lower urinary tract symptoms which include urinary urgency, dysuria, and recurrent urinary tract infections.

Three large Internet and telephone studies funded by Novo Nordisk, Shionogi, Inc, Pfizer Pharmaceuticals, and Wyeth have recently reported the prevalence of GSM symptoms in postmenopausal women in the United States, Canada, and Europe.[2,3,4,5] These works demonstrate that postmenopausal women commonly experience symptoms from GSM. In the REVIVE study of 10,486 US women, 38% of postmenopausal women reported vulvovaginal symptoms in the last 12 months and 59% of women with symptoms reported an impact on their enjoyment of sex.[2] Other themes emerging from these studies were that many women reported a loss of intimacy with their partner or did not seek a new partner due to GSM.[2,4] Finally, many women believe that vaginal discomfort is a "natural part of growing older" and do not seek medical treatment for these symptoms.[3] Although these studies provide both valuable information about the prevalence of VVA in postmenopausal women, impact of VVA symptoms on sexual activity, and about treatment-seeking behavior and discussions with healthcare providers, less is known about the impact of VVA symptoms on domains of quality of life (QoL), beyond sexual function. Finally, the overlap of symptoms that postmenopausal women experience symptoms from pelvic floor disorders (PFDs) and general menopausal symptoms with GSM is not known.

The development of validated patient-reported outcome measures to capture GSM was outlined as a research goal by the Vulvovaginal Atrophy Consensus Panel convened in 2013. In 2010, we began the development process for a valid and internally consistent measure for VVA that would include both symptoms and disease-specific QoL impact of VVA symptoms on multiple domains (emotional, lifestyle, and sexual) with multiple items. We first convened an expert panel to develop items. Then, we conducted cognitive interviews, and finally three focus groups to develop the Vulvovaginal Symptom Questionnaire (VSQ).[6] The VSQ was then tested for validity and internal consistency using physical examination and other validated questionnaires in 120 postmenopausal women presenting for gynecologic care. In this work, we seek to expand on our previous work by having postmenopausal women complete the VSQ to estimate the prevalence of symptoms and further solidify answer responses.

The primary objective of this study was to use a valid and internally consistent survey instrument, the Vulvovaginal Symptom Questionnaire (VSQ), to estimate the prevalence of vulvovaginal symptoms and examine the emotional, lifestyle, and sexual impact of vulvovaginal symptoms in postmenopausal women. Our secondary objective was to determine if responses assessed about degree of bother of vulvovaginal symptoms provided more information than dichotomous responses assessed about the presence or absence of symptoms. Other secondary objectives included a comparison of gynecologic diagnoses, treatments received, and hormone therapy (HT) in women with and without vulvovaginal symptoms and an examination of the association between current vulvovaginal symptoms with PFDs and general menopausal symptoms using validated questionnaires.