Clinician Knowledge, Attitudes, and Barriers to Management of Vulvovaginal Atrophy

Variations in Primary Care and Gynecology

Kimberly K. Vesco, MD, MPH; Kate Beadle, NP, NCMP; Ashley Stoneburner, MPH; Joanna Bulkley, PhD; Michael C. Leo, PhD; Amanda L. Clark, MD, MCR, NCMP


Menopause. 2019;26(3):265-272. 

In This Article

Abstract and Introduction


Objective: Vulvovaginal atrophy is a common, but under-recognized condition affecting postmenopausal women. To guide development of an intervention to boost its detection and treatment, we surveyed primary care and gynecology clinicians practicing in an integrated healthcare system.

Methods: We constructed a three-part survey that contained (1) eight multiple-choice knowledge questions; (2) three Likert-scale questions regarding clinicians' likelihood of assessing for vulvovaginal atrophy symptoms at a routine (well) visit, confidence in advising patients about symptoms and counseling about therapy; and (3) a 12-item check list of potential barriers to diagnosis and treatment. Analyses were performed using multiple regression.

Results: Of the 360 clinicians who were sent an e-mail request, 119 (90 primary care, 29 gynecology) completed the survey (33%). Responders and nonresponders did not differ by age, specialty, or clinician type. The proportion with correct responses to knowledge questions differed between primary care (63%) and gynecology (77%) (adjusted mean difference [AMD] =16, 95% CI [10–22]). Primary care clinicians were less likely than gynecology clinicians to assess for symptoms (AMD=1.04, 95% CI [0.55–1.52]), and were less confident about their ability to advise on symptoms (AMD = 0.66, 95% CI [0.33–0.99]) and to counsel patients about treatment (AMD=0.76, 95% CI [0.42–1.10]). Lack of time (71%) and educational materials (44%) were the most common barriers to diagnosis and treatment.

Conclusions: Primary care and gynecology clinicians differ in their knowledge and confidence in managing vulvovaginal atrophy but report similar practice barriers. Addressing identified knowledge deficits and practice barriers may lead to improved management of vulvovaginal atrophy. Key Words: Genitourinary syndrome of menopause – Vulvovaginal atrophy.


Vulvovaginal atrophy (VVA), now recognized as a part of the genitourinary syndrome of menopause (GSM), is a chronic and progressive condition that includes symptoms of vulvovaginal dryness and irritation, painful intercourse, dysuria, urinary urgency, urge incontinence, and recurrent urinary tract infections.[1] VVA can have a serious impact on many women's quality of life. A survey of postmenopausal women and their partners, Clarifying Vaginal Atrophy's Impact on Sex and Relationships (CLOSER), found that both women and men report that VVA results in avoidance of intimacy, loss of libido, and painful sex.[2]

Two online surveys of US women aged 55 to 65, the Women's Voices in the Menopause (2009) and Vaginal Health: Insights Views, & Attitudes (VIVA, 2010), found that approximately half of postmenopausal women (43% and 48%, respectively) had experienced symptoms related to VVA.[3,4] Furthermore, over half of the women with vulvovaginal symptoms reported the symptoms were moderate to severe. Yet one-third of symptomatic women (33% and 37%, respectively) had not discussed their symptoms with a healthcare professional (HCP).[3,4] Reasons women gave for not speaking to an HCP about VVA symptoms included embarrassment, feeling it was inappropriate to discuss symptoms with others, and a belief that the symptoms were a natural part of aging.[3] Some (20%) also preferred that their HCP be the initiator of conversations about vulvovaginal symptoms.[3] From the Women's EMPOWER survey: Identifying Women's Perceptions on Vulvar and Vaginal Atrophy and Its Treatment (2016), most women (81%) did not view VVA as a medical problem, but instead a natural part of aging and something to live with.[5] Most women (72%) indicated reluctance in bringing the subject up with their HCP, but most (87%) indicated that they would be likely to discuss their vaginal symptoms if the HCP initiated the conversation. When comparing survey results over time (2009–2016), lack of awareness of VVA has been quite consistent despite a marked increase in media attention to VVA.[6]

Although professional organizations such as the American College of Obstetrics and Gynecology (ACOG), The North American Menopause Society (NAMS), and Endocrine Society recognize that the routine evaluation and treatment of GSM symptoms are an important aspect of menopausal health,[7–9] symptomatic postmenopausal women are not often evaluated by their HCP's for their symptoms. In a survey of 2,791 postmenopausal women with VVA symptoms who indicated they had an HCP for gynecologic needs, only 19% of them indicated that their HCP asked about their sexual health during a routine gynecologic examination and only 13% said their HCP had initiated a conversation with them about VVA symptoms specifically.[10] In the more recent EMPOWER study, only 14% of women reported that their HCP initiated a conversation.[5]

Plausible interventions to address these care gaps include providing additional education about vulvovaginal health to the relevant clinicians, gynecologists and primary care clinicians. Effective curriculum development requires the foundational step of performing a needs assessment for the prospective learners.[11] Although there have been several surveys of postmenopausal women and their vulvovaginal health and health-related concerns,[3,4,10] little is known about US primary care (PC) (comprising internal medicine and family practice) and gynecology (GYN) clinicians' knowledge, attitudes, and practices related to VVA. Currently, published clinician surveys are related primarily to women's care during the climacteric[12] and are limited in furthering our understanding of PC and GYN knowledge and practices related to VVA in postmenopausal women. As a formal needs assessment to guide an educational intervention to improve management of VVA, we conducted a survey of PC and GYN clinicians practicing in our healthcare system to ascertain their knowledge about the prevalence and progression of VVA, their practices regarding diagnosis and treatment of VVA, and their perceived barriers to the diagnosis and treatment of VVA. Recognizing the differences in the broad general training of PC clinicians and the focused specialty training of gynecologists, we tested for differences between PC and GYN clinicians in knowledge, practice, and barriers to VVA diagnosis.