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


The present study assessed the overall impact of VVA symptoms on the quality of life of postmenopausal women attending menopause and/or gynecology clinics in Southern Europe (Italy and Spain). The main analysis focused on the relationship between the severity of groups of VVA symptoms and quality of life measures, both generic (EQ-5D-3L) and related to vaginal aging (DIVA questionnaire). Our study population is representative of Italian and Spanish postmenopausal women visiting gynecology and menopause clinics.

In line with previous findings,[8,11,22,23,17] the results of this subanalysis of the EVES study show that both generic and vaginal aging-related quality of life scores showed a significant relationship with the different types of severe VVA symptoms. Previous evidence of this relationship came from indirect measurements, not using specific quality of life questionnaires.[8,11,22,23] The only comparable study is a cross-sectional Internet survey,[17] which focused on women in peri- and postmenopausal ages and used only the generic EQ-5D-3L questionnaire to evaluate quality of life. In that study, conducted by DiBonaventura et al,[17] only 50% of women reported moderate or severe symptoms.

There was a statistically significant association between worse quality of life as measured by EQ-5D-3L and VAS scores and the presence of severe symptoms in our sample of postmenopausal women attending menopause and/or gynecology clinics. Interestingly, this association was observed for all types of severe symptomatology (vaginal, vulvar, and urinary), but was most prominent in women with severe urinary symptoms. This result is in line with the aforementioned study on the association of EQ-5D-3L score with the severity of VVA symptoms,[17] but our study allows for the differentiation and relative quantification of this effect according to the main group of VVA symptoms reported as severe. This may help clinicians to focus their therapeutic efforts on those symptoms that have the largest impact on quality of life.

The DIVA overall score, which is a multidimensional scale specifically designed to measure the impact of vaginal symptoms and aging on the functioning and well-being aspects of quality of life,[24] demonstrated better correlation with symptom severity than the more generic EQ-5D-3L. The clinical meaningfulness of the correlations should, however, be assessed with caution, as we were only able to detect relatively moderate correlations. Interestingly, compared with vaginal and vulvar symptoms, the severity of urinary symptoms more strongly influenced all DIVA components. This confirms recently reported observations on predictors of impact of vaginal symptoms, in which women with urinary incontinence reported a higher impact of VVA symptoms on three of the four DIVA dimensions (not sexual functioning).[25]

Within the context of the EVES survey, VVA confirmation by gynecologic examination was included in the analysis. Quality of life (EQ-5D-3L and DIVA) was statistically significantly lower in women with VVA confirmed by this examination. This suggests that postmenopausal women attending menopause and/or gynecology clinics and with VVA confirmed by a physician have lower generic and VVA-specific quality of life scores. This may indicate a delay in seeking help in VVA-affected women that compromises the management and treatment of VVA, as suggested elsewhere.[6,19]

There are some weaknesses in this study. Our overall results may be compromised by issues related to the intrinsic selection bias associated with nonrandomized studies that have no control group and with the observation that many women with VVA do not seek treatment or visit menopause or gynecology clinics. On the contrary, some compelling strengths deserve to be highlighted. First, the face-to-face interview, instead of the online environment of most previous studies, provides improved reliability to our survey. Second, the clinical assessment of VVA by gynecologic examination is unique and new in an observational study. Finally, compared with the generic quality of life instrument (EQ-5D-3L) the VVA-specific quality of life tool (DIVA) demonstrated higher sensitivity and a stronger correlation with the symptomatology observed in this study.