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


Demographic and Baseline Characteristics

A total of 2,412 postmenopausal women were screened in the original EVES survey in Italy and Spain between May 2015 and March 2016 at a total of 46 outpatient menopause centers (n = 1,519; 63%) and gynecology centers (n = 893; 37%). Among them, 2,403 were evaluable for symptom screening and 2,160 had at least one symptom related to VVA. This group of participants was included in the present analysis and moved on to the next step of the survey by filling in the questionnaire on symptoms, as well as the EQ-5D-3L and DIVA questionnaires. They also had a gynecologic clinical examination.

Demographic characteristics of the participants are summarized in Table 1. Almost two-thirds (66.3%) of the participants suffered from severe vaginal symptoms; 30.5% suffered from severe vulvar symptoms and 11.2% from severe urinary symptoms (women could suffer from more than one symptom). Approximately 29.3% of participants did not report any severe symptoms (vaginal, vulvar, or urinary). The number of participants and overlapping groups with severe symptoms are presented in Figure 1. Mean (±SD) age of the included women was 58.9 ± 6.8 years and mean (±SD) time since menopause was 10.1 ± 7.1 years. Overall, the prevalence of VVA confirmed by gynecologic examination was 90.5% (1,954 out of 2,160). The prevalence was 93.5%, 94.4%, and 91.4% in women with severe vaginal, vulvar, and urinary symptoms, respectively, and 83.4% in women without severe symptoms. The most commonly reported symptoms associated with VVA were vaginal dryness (87.6%) and pain during intercourse (66.8%). No apparent differences in demographic and baseline characteristics were observed between women with or without severe symptoms, except for the lower rate of sexual activity (mean rate of sexual intercourse per month) reported by participants with severe vaginal or vulvar symptoms in comparison with those with no severe symptomatology (t test, P < 0.0001) (Table 1).

Figure 1.

Venn diagram illustrating the total number of surveyed postmenopausal women with severe symptoms (N = 1,527) and their corresponding overlapping groups.

Quality of Life: The EuroQol Questionnaire (EQ-5D-3L)

Results from the EQ-5D-3L questionnaire on quality of life were summarized and analyzed according to the presence of severe vaginal, vulvar, or urinary symptoms (Table 2). In the overall population, the mean (±SD) EQ-5D-3L overall score was 0.892 ± 0.144 and the mean (±SD) score for the associated VAS was 71.7 ± 16.0. In the cohort of participants that did not suffer from severe symptoms (N = 633), mean (±SD) EQ-5D-3L overall score and VAS score were higher (0.918 ± 0.119 and 73.8 ± 15.7, respectively) than in the cohort of participants with severe symptoms (0.882 ± 0.152 and 70.9 ± 16.0, respectively, P < 0.0001, in both cases), reflecting a better quality of life in women without severe symptoms. The differences in EQ-5D-3L overall score and VAS score were most pronounced in women with severe vulvar and urinary symptoms (Table 2).

The poorer quality of life in the severe symptom population was seen in all five dimensions of the EQ-5D-3L (Table 2). Usually, women with severe vulvar symptoms and those with severe urinary symptoms had higher rates of problems in all EQ-5D-3L dimensions than those with severe vaginal symptomatology.

Quality of Life: The DIVA Questionnaire

A similar trend was seen in the relationship between severity of symptoms and DIVA score. DIVA overall score and scores for the individual components (daily activities, emotional well-being, sexual functioning, and self-concept/body image) were significantly worse for women with severe VVA symptoms (vaginal, vulvar, or urinary) compared with those women not affected by severe symptoms (P < 0.0001, in all cases, Table 3).

Although always statistically significant, the impact of severe symptoms was slightly lower for the sexual functioning component and daily activities component. For the emotional well-being component and the self-concept/body image component, scores for women with severe VVA symptoms were, however, 2 to 3 times as high compared with scores for women without severe VVA symptoms (Table 3). Severe vulvar symptoms and especially severe urinary symptoms affected, in a higher magnitude, all the DIVA components with the exception of sexual functioning which seems to be influenced by severe vaginal as well as severe vulvar symptoms (Figure 2).

Figure 2.

Impact of the presence of severe symptoms on DIVA overall scores and scores for the individual DIVA components: (A) severe vaginal symptoms; (B) severe vulvar symptoms; (C) severe urinary symptoms. DIVA, Day-to-Day Impact of Vaginal Aging questionnaire.

Quality of Life According to VVA Status Confirmation

Quality of life was also analyzed according to VVA diagnosis confirmation. The mean EQ-5D-3L score was lower in participants whose VVA was confirmed by a specialist through a gynecologic examination than in those where the examination did not confirm signs of VVA (0.890 vs 0.913, P < 0.05); for the VAS, the difference did not reach statistical significance (71.5 vs 73.7, P = 0.060). Regarding EQ-5D-3L dimensions, a statistically significant higher rate of problems was reported for the mobility dimension in women with confirmed VVA and a trend to a higher rate of serious problems was observed for the pain/discomfort dimension (see Supplementary Digital Content 1, for details).

The DIVA overall score was also significantly worse (higher) in women where the diagnosis of VVA was confirmed by gynecologic examination than in those where this was not the case (0.939 vs 0.769, P < 0.0001). This also applied to the majority of individual DIVA components (see Supplementary Digital Content 2, for details). The most detrimental effect was observed for the self-concept/body image component of the DIVA score (1.019 in women with VVA diagnosis confirmation vs 0.723 in women without VVA confirmation).

Correlation Between VVA Symptoms and Quality of Life

Correlations between overall and specific symptom scores and results from the quality of life questionnaires (EQ-5D-3L and DIVA) were also examined (Table 4). Although statistically significant (P < 0.01, two-sided), correlations of EQ-5D-3L overall score, VAS score, and scores for most EQ-5D-3L components with vaginal, vulvar, urinary, and overall symptoms scores were very weak. DIVA overall score correlated moderately with vaginal symptom severity score (Spearman rho = 0.484), vulvar symptom severity score (rho = 0.427), and overall symptom severity score (rho = 0.504). Analyzing in detail, the components that showed moderate correlations with symptom scores were emotional well-being and self-concept/body image, especially with vaginal (0.369 and 0.468, respectively) and vulvar symptoms scores (0.359 and 0.403, respectively) (see Table 4 for details).