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

Disclosures

Menopause. 2019;26(3):265-272. 

In This Article

Results

Of the 360 clinicians who were sent an e-mail request, 119 completed the survey (33%). Female clinicians were more likely to respond than male clinicians, but there was no difference in survey response with respect to age, specialty, or type of clinician (Table 2). When comparing survey responders, gynecology clinicians are more likely to be a woman and more likely to be an advanced practitioner (Table 3).

Clinicians answered 66% of the knowledge questions correctly. Questions about VVA prevalence and treatment in women with a history of breast cancer received the lowest proportion of correct responses (GYN, 35% and PC, 18%; Table 4). Overall, there were more correct answers from GYN clinicians (77% correct, ranging from 50% to 100%) than PC clinicians (63% correct, ranging from 25% to 88%) (adjusted mean difference = 16, 95% CI [10–22]). A greater proportion of GYN clinicians correctly answered two questions about VVA treatment and estrogen therapy for VVA (question 4:GYN90%vs PC 63%; adjusted OR 6.33, 95%CI [1.74–23.1] and question 5: GYN 97% vs PC 69%; adjusted OR=16.9, 95% CI [2.64–108]) as well as a question about use of vaginal estrogen therapy for urinary symptoms (question 8: GYN 76% vs PC 48%; adjusted OR=3.52, 95% CI [1.31–9.48]).

With regard to practice behavior items, overall, 39% of clinicians were highly likely or likely to assess for VVA during a routine visit; 43% had high or very high confidence in advising patients about VVA symptoms; and 42% had high or very high confidence in advising patients about vaginal estrogen treatment. Compared with PC clinicians, more GYN clinicians reported: (1) being highly likely or likely to assess for VVA symptoms during a routine visit (72% vs 28%); (2) being highly or very highly confident about their ability to counsel on VVA symptoms (72% vs 33%); and (3) being highly or very highly confident to advise on risks/benefits of vaginal estrogen (76% vs 30%). When examining the practice behavior items over the entire range of the scale and after adjusting for covariates, a difference in reported practice behavior persisted. PC clinicians reported being less likely to assess for VVA symptoms during a routine visit than GYN clinicians (adjusted mean difference = 1.04, 95% CI [0.55–1.52]) (Table 5). In addition, PC clinicians were less confident than GYN clinicians about their ability to counsel on VVA symptoms (adjusted mean difference = 0.66, 95% CI [0.33–0.99]) and to advise patients about the risks and benefits of vaginal estrogen (adjusted mean difference = 0.76, 95% CI [0.42–1.10]).

When considering barriers to VVA diagnosis and treatment (Table 6), we found that lack of time (71%) and lack of educational materials for patients (44%) were the most commonly identified barriers while difficulty discussing sexual or urinary symptoms with patients were the least commonly identified barriers (2%). More than 1 in 3 clinicians identified the designation of systemic estrogen as a high-risk medication among older women as a barrier to treatment of VVA.

GYN clinicians identified five barriers more often than PC clinicians: estrogen as a high-risk medication among older women (adjusted OR = 1.09, 95% CI [0.44–2.73]), the FDA ''black box'' warning for vaginal estrogen prescriptions (adjusted OR=1.36, 95% CI [0.53–3.48]), patient dissatisfaction with options for vaginal estrogen (adjusted OR=2.29, 95% CI [0.90–5.81]), and lack of educational materials for patients (adjusted OR=2.24, 95% CI [0.92–5.49]); however, the only significant difference between GYN and PC clinicians was in the selection of the cost of vaginal estrogen therapy as a barrier (GYN 48%, PC 18%, adjusted OR=4.77, 95% CI [1.76–12.94]).

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