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


We found that, compared with primary care clinicians, gynecology clinicians have greater knowledge about VVA, are more likely to screen women for VVA symptoms at a routine visit, and are more confident about their ability to counsel women about VVA treatment options. Although this is not surprising given the focus on women's health in gynecologic training, it is concerning because millions of postmenopausal women see only a primary care clinician after the cessation of pap testing. In a review of EHR data in KPNW, we found that a minority of coded well care visits for postmenopausal women were conducted by gynecologists and that the proportion decreases with advancing age (Table 1). This statistic is very likely to be influenced by practice patterns within KPNW, in which highly integrated care is organized by the primary care clinician. All members of KPNW are encouraged to have a primary care clinician and the well-woman examination is considered within the purview of primary care clinicians. Woman may choose to have well care from a gynecologist at no additional cost, but most women find it more convenient to receive this care from their primary care clinician. There have been no policy changes likely to affect this distribution since the time of the study.

Recommendations from ACOG and the U.S. Preventive Services Task Force (USPSTF) to discontinue routine cervical cancer screening after age 65[20,21] among women at low risk for cervical cancer have a direct impact in curtailing regular examinations of the vulva. The frequency of cervical cancer screening that requires a pelvic examination is largely determined by EHR reminders to clinicians and directly to women, and the design of the EHR reminder system is guided by internal KPNW guidelines that are reviewed and revised every 2 years (or at the time of a major national guideline change.) Going forward, the frequency of vulvovaginal examination is likely to be further reduced by the USPSTF recommendation in 2017 stating there is insufficient evidence to perform routine pelvic exams in women who do not need cervical cancer or sexually transmitted infection screening.[22] The influence of national guidelines and recommendations is likely to increase as clinicians' priorities are influenced by medical record systems designed around these guidelines. National surveys of symptomatic postmenopausal women suggest that at least one-third of women do not seek or delay seeking care for their symptoms,[10,14] and many expect their HCP to raise the issues of vulvovaginal and sexual health with them.[10,14] Therefore, unless women actively seek treatment for VVA, their symptoms and findings may go unrecognized. Our health system lacks design features or incentives to detect and treat VVA.

Clinicians report challenges in addressing menopause generally in keeping with our findings regarding VVA specifically. In a national survey of practicing primary care and gynecology clinicians regarding the treatment of menopause, physicians reported challenges to communication with women about menopause, including confusing messages from the media (80%), inconclusive data about hormone therapy (56%), complicated issues around treatment options (45%), and time constraints (43%).[12] Given that women may spend up to one-third of their lifespan in the postmenopausal period,[23] it is critical to ensure that gynecologists and primary care clinicians are adequately prepared through residency training to screen for, diagnose, and treat symptomatic vulvovaginal atrophy and urinary disorders.

Unfortunately, menopause education is lacking in many residency programs in OBGYN. A web-based survey of residents from 258 US OBGYN residencies found that a majority of residents reported limited knowledge regarding menopause medicine.[24] A large number of fourth-year OBGYN residents reported the need to learn more about the pathophysiology of menopausal health, as well as hormone and nonhormone therapies, before independent practice; and they indicated that they preferred experiential (clinic-based) or case-based learning opportunities. NAMS and ACOG have jointly created an academic curriculum that will address education and tools needed to manage menopausal health.[25] Additional work may be needed in OBGYN training programs to ensure that residents have adequate opportunities to care for postmenopausal women under the guidance of clinical proctors with experience in menopausal and urinary health.

We found no assessments of knowledge and training related to menopause and VVA in family practice and internal medicine residencies. Women's health fellowships were first created in 1990 to improve women's health education in primary care, but their adoption has been limited.[26] In 2016, there were only 26 fellowships in internal medicine and 8 residencies with a women's health track.[27] The American Academy of Family Physicians currently lists 8 fellowship opportunities in women's health.[28] These are a very small proportion of the currently ACGME-accredited internal medicine (511) and family medicine (583) residency programs.[28] The national curriculum for women's health in family medicine residencies includes menopause and urogynecology as general topics, but there is no mention of VVA or any vulvar condition affecting midlife and older women.[29] The ACGME program requirements for internal medicine include this single statement ''Residents should receive instruction and clinical experience in the prevention, counseling, detection, and diagnosis and treatment of sex-specific diseases of women and men'' out of 158 pages of requirements.[30] Overall, menopause education receives little emphasis in both OBGYN and PC residency training.

In our survey, both GYN and PC clinicians denied discomfort with discussing VVA symptoms with patients, but their knowledge about VVA and their confidence in their ability to diagnose and treat symptomatic VVA differed substantially. The knowledge deficits were primarily related to treatment of VVA, and PC clinicians lacked confidence in their ability to advise patients on VVA symptoms and treatment. Our findings, along with those of the national survey, suggest that family and internal medicine residents may benefit from additional training regarding GSM. In fact, it may be even more important for these clinicians, who will be caring for a large portion of the aging female population.

Our survey confirmed the presence of barriers to treating VVA. One-third of clinicians identified the warning about estrogen as a high-risk medication for older women as a barrier. Whereas the warning (identified by the AGS Beers list and NCQA HEDIS) only applies to systemic estrogen,[16] misapplication of the warning to vaginal estrogen could limit clinicians' use of vaginal estrogen products, which are quite effective in treating symptomatic VVA. A related barrier, also identified by about one-third of clinicians surveyed, is the package labeling for vaginal estrogen products, which contains the same black box warning as systemic estrogen products regarding increased risks for myocardial infarction, venous thromboembolism, stroke, breast cancer, and dementia, and provides risk estimates for these events based on studies of systemic estrogen use. Although NAMS, ACOG, and the Endocrine Society have produced clinical practice guidelines that contradict the FDA package labeling regarding the risks associated with vaginal estrogen use,[7–9] the conflicting information may limit clinician and patient enthusiasm for these products.

The survey response rate of 33% was less than desired, but the rate compares favorably to the response rate of 24% in the national survey of PC and GYN clinicians regarding overall menopause care.[12] Female clinicians were more likely to be survey respondents, but gender did not predict survey responses. Although our survey was limited to a small sample of clinicians in a large healthcare system whose practice barriers may be different from those of individual practitioners in other healthcare or geographic settings, it does represent a spectrum of clinicians from various training institutions and educational backgrounds. The perception of some barriers is likely to be influenced by certain characteristics of the KPNW health system. The design of the EHR ensures that clinicians are aware of the high-risk designation of systemic estrogen. The highly customized EHR provides a prominent Best Practice Alert for any current medications that are designated as high risk in older women during every clinical encounter. The alert is triggered for any woman age 64 or older by systemic estrogen prescriptions and list of nonhormone alternatives is provided. The alert offers vaginal estrogen as a safe option for VVA, but this is much less prominent than the overall alert. In addition, clinicians' experience is limited by formulary treatment options that are approved by the Pharmacy and Therapeutics Committee, which performs careful cost/benefit analyses for each therapeutic class. For VVA, a single vaginal cream, a suppository and a vaginal ring were on formulary at the time of the study, but the oral agent ospemifene was not. Nonformulary medications may be prescribed at a higher cost for member, but this greatly reduces use and therefore clinician experience with the newer, more costly therapies. Intravaginal dehydroepiandrosterone (DHEA) was not yet FDA-approved at the time of this study.

A national structural barrier to receipt of care for symptomatic VVA among women aged 65 and older exists in the specifications of Medicare reimbursement for the Annual Wellness Visit.[32] Women over age 65 are directed to primary care clinicians for a more comprehensive Annual Wellness Visit every 2 years. Assessment of VVA symptoms is not a routine part of a Medicare Annual Wellness Visit. Therefore, unless women bring up symptoms of VVA to their clinician, ongoing issues are likely to remain undetected and untreated. Incorporating VVA symptom assessment into routine Medicare Annual Wellness Visit health questionnaires may help primary care clinicians identify, diagnose, treat, and/or refer symptomatic patients. Although gynecologists do not perform the Medicare Annual Wellness visits, gynecologists may bill Medicare for cervical cancer screening and pelvic exams, and problem-focused visits.[31] Therefore, gynecologists should also include detailed vulvovaginal, sexual, and urinary symptom checklists on office-visit health questionnaires for postmenopausal women.