The Burden of Vulvovaginal Atrophy on Women's Daily Living

Implications on Quality of Life From a Face-to-face Real-life Survey

Rossella E. Nappi, MD, PhD; Santiago Palacios, MD, PhD; Nico Bruyniks, MD, MRCOG, MFSRH; Martire Particco, MD; Nick Panay, BSc, FRCOG, MFSRH; on behalf of the EVES Study investigators


Menopause. 2019;26(5):485-491. 

In This Article

Abstract and Introduction


Objective: This subanalysis of the European Vulvovaginal Epidemiology Survey study aimed to assess the correlation of vulvovaginal atrophy (VVA) symptoms and severity, when confirmed by objective gynecologic examination, with the quality of life of postmenopausal women.

Methods: Women aged 45 to 75 years with confirmation of last menstrual period more than 12 months before, who attended menopause or gynecology centers, were included. Those women had at least one VVA symptom filled in a group of questionnaires, including EuroQol-EQ-5D-3L and Day-to-Day Impact of Vaginal Aging (DIVA). To confirm the VVA diagnosis, an objective gynecologic examination was also performed.

Results: Of a total of 2,160 evaluable women, 66.3%, 30.5%, and 11.2% suffered from severe vaginal, vulvar, and urinary symptoms, respectively. VVA was confirmed in more than 90% of the participants. Mean (±SD) EQ-5D-3L score was 0.892 ± 0.144 and mean (±SD) score on the associated visual analog scale was 71.7 ± 16.0. Mean (±SD) DIVA score was 0.922 ± 0.653. For both EQ-5D-3L and DIVA, the overall scores and most of the dimensions/components were statistically significantly worse for women with severe VVA symptoms (vulvar and urinary) compared with women not affected by severe symptoms. Quality of life questionnaires showed worse scores in women where the diagnosis of VVA was confirmed by gynecologic examination.

Conclusions: Severe VVA symptoms showed a direct association with worse quality of life in postmenopausal women. This important effect on the quality of life of many women should be recognized as equivalent to those from other conditions and pathologies of which there is greater awareness.


The menopausal condition of vulvovaginal atrophy (VVA) is caused by a reduction in circulating estrogen levels after menopause, which results in physiological, anatomic, and functional changes in the estrogen receptor-enriched mucosa of the lower genital and urinary tracts.[1] Vaginal collagen, vascularization, and mucopolysaccharides decrease with declining estrogen levels. This, in turn, reduces the thickness and moisture of the vagina.[2] The vaginal epithelium switches to a thinner, squamous, and stratified epithelium, the vaginal wall loses elasticity, the lactobacilli content is reduced, and vaginal pH increases to over 5.[3]

VVA is highly prevalent in postmenopausal women. Based on physical examinations, prevalence estimates range from 67%[4] to 98%.[5] In about 50% of postmenopausal women, VVA leads to symptoms.[6,7] Vaginal dryness is the most frequent symptom of VVA and one of the major contributors to the associated sexual dysfunction.[8] Vaginal dryness, together with other VVA symptoms such as dyspareunia, vulvar and vaginal irritation and itching and postcoital bleeding, are determining factors of the impaired quality of life acknowledged by postmenopausal women.[9–11] Despite the impact these symptoms have on quality of life, women frequently considered them as part of normal aging. This discourages them from consulting their healthcare providers,[1,11] leading to underreporting.[12] VVA symptomatology is also associated with heightened psychosocial distress.[13–15] Furthermore, the embarrassment many women feel when discussing sexual issues is strongly linked with communication constraints between women and physicians.[16]

Although specific studies on the relationship between VVA symptoms and quality of life are scarce, some survey data indicate that VVA is associated with a clinically significant impact on quality of life that may be comparable to that seen in serious conditions such as arthritis, chronic obstructive pulmonary disease, asthma, and irritable bowel syndrome.[17,18] Because of its prevalence and substantial impact on quality of life, managing VVA and identifying it as a medical condition are a priority to optimize postmenopausal women's health care.[6]

The main objective of the European Vulvovaginal Epidemiology Survey (EVES) was to describe the prevalence of VVA confirmed by gynecologic clinical assessment among women attending menopause/gynecologic centers. The focus of the present work is on the secondary objective of the EVES study: to assess the correlation of VVA symptoms, when confirmed by objective gynecologic examination, with quality of life of postmenopausal women.