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VIVA Survey by Dr Nappi Climacteric 2012 (2)

VIVA Survey by Dr Nappi Climacteric 2012 (2)

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CLIMACTERIC 2012;15:36–44
ORIGINAL ARTICLE Received 25-08-2011© 2012 International Menopause Society Revised 07-11-2011DOI: 10.3109/13697137.2011.647840 Accepted 20-11-2011
 Correspondence: Professor R. E. Nappi, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause Unit, Departmentof Obstetrics and Gynecology, IRCCS ‘S Matteo Foundation, University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy 
dryness
2
 , resulting from reduced transudation through thevaginal epithelium and reduced cervical gland secretions.Indeed, when vaginal atrophy is present in menopausalwomen, vaginal dryness is commonly the first symptomreported
4
 . The number of women reporting vaginal drynessincreases from early to late perimenopause
5
 , and the preva-lence subsequently increases as women advance through thepostmenopausal years
1
 . Other symptoms of vaginal atrophytypically include irritation, itching, discharge and, amongsexually active women, dyspareunia and other forms of sexual dysfunction
1,6
 . In addition, urinary symptoms (suchas frequency, urgency, nocturia, dysuria, incontinence andrecurrent infections)
7,8
occur more frequently when vaginalatrophy is present. In a United States-based survey of women
INTRODUCTION
Ovarian failure during menopause produces a marked declinein estrogen levels that affects many organ systems
1
 . However,the urogenital tract – specifically, the vagina, urethra, bladder,trigone and pelvic floor muscles
2
– is particularly sensitive toestrogen deprivation
1
 , and a lack of local estrogen is theprimary cause of atrophy in these tissues and structures
3
 . Asa result, approximately 50% of postmenopausal women willexperience symptoms relating to urogenital atrophy, withsubsequent impact on sexual function and quality of life
1
 .Vaginal atrophy associated with estrogen depletion becomesclinically apparent 45 years after the menopause
1
 . Chronicreduction in estrogen levels ultimately leads to vaginal
Vaginal Health: Insights, Views & Attitudes(VIVA) – results from an international survey
R. E. Nappi and M. Kokot-Kierepa*
 
Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause Unit, Department of Obstetrics andGynecology, IRCCS ‘S Matteo Foundation, University of Pavia, Pavia, Italy; *
 
Novo Nordisk FemCare AG, Zurich, Switzerland
Key words:
ATTITUDE, MENOPAUSE, POSTMENOPAUSE, SURVEY, VAGINAL ATROPHY, VAGINAL HEALTH
ABSTRACT
Objective
To assess knowledge of vaginal atrophy among women using the Vaginal Health: Insights,Views & Attitudes (VIVA) survey.
Methods
A structured online questionnaire was used to obtain information from 3520 postmenopausalwomen aged 5565 years living in Great Britain, the United States, Canada, Sweden, Denmark, Finland, andNorway.
Results
In total, 45% of women reported experiencing vaginal symptoms. Only 4% of women attributedthese symptoms to vaginal atrophy, and 63% failed to recognize vaginal atrophy as a chronic condition.Overall, 44% of respondents did not have a gynecologist, but this percentage varied between countries. Mostwomen (75%) felt that vaginal atrophy had a negative impact on life, but this perception also showedcountry-specific differences. Most Finnish respondents (76%) were satisfied with the amount of informationavailable about vaginal atrophy, compared with just 3742% of women from other countries. Most womenused over-the-counter products for vaginal atrophy symptoms, but specific means of treating the underlyingcause were less well known. Almost half (46%) of all respondents lacked knowledge about local estrogentherapy, with women in Great Britain, the United States and Canada being most likely to lack knowledge of such treatment. Overall, 30% of women would consider taking local estrogen therapy, with vaginal tabletsbeing the preferred option in all countries.
Conclusion
Postmenopausal women have a low understanding of vaginal atrophy. Medical practitionersshould proactively raise this topic, help patients to understand that vaginal atrophy is a chronic condition,and discuss treatment options. Country-specific approaches may be required.
   C   l   i  m  a  c   t  e  r   i  c   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   N  o  v  o   N  o  r   d   i  s   k   A   /   S   (   A   C   T   I   V   E   )  o  n   0   1   /   1   0   /   1   2   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
 
Vaginal health survey Nappi and Kokot-Kierepa
Climacteric 37
aged 45 years or older, 60% of past or non-users of meno-pausal hormone therapy had experienced vaginal symptoms,with over 90% reporting them to be bothersome
9
 .Despite the high prevalence and diversity of symptomsassociated with vaginal atrophy, and despite their markedimpact on sexual function and quality of life, only around one-quarter of symptomatic women seek medical help
10
 . Womenare often reluctant to consult their doctors about vaginalsymptoms, perhaps due to embarrassment, cultural values, oracceptance of such symptoms as an inevitable consequence of aging
1,2
 . Furthermore, many women might not be fully awareof the link between vaginal discomfort and declining estrogenlevels
1
 , or may be concerned about withdrawal bleeding andthe possible increased risk of breast cancer associated withlong-term estrogen use
10
 , particularly with systemic thera-pies. However, providing women with an opportunity to talkabout sexual health is a fundamental aspect of good healthcare
11
 , and most women express relief and respond positivelywhen health-care professionals initiate such discussions
1
 .Furthermore, the treatment of vaginal atrophy has positiveeffects on womens general and sexual quality of life
12,13
 .Medical practitioners should therefore initiate and engage inopen, sensitive dialogue with postmenopausal women aboutthis aspect of their health
1
 , so that symptomatic vaginalatrophy can be detected early and appropriate managementinitiated before irreversible atrophic changes occur
1
 .In a recently reported survey involving interviews with4246 women aged 5565 years living in Sweden, Finland, theUnited Kingdom, the United States and Canada, we reportedthat, although 39% of the postmenopausal cohort had expe-rienced vaginal atrophy, 77% of the interviewees believed thatwomen were uncomfortable discussing the condition and42% were unaware of the availability of local treatment
14
 .This article presents the results of the new ‘Vaginal Health:Insights, Views & Attitudes (VIVA)’ survey, which was con-ducted in Europe and North America to further explore wom-ens knowledge regarding vaginal health and, in particular,vaginal atrophy. The goals of this survey are to increase aware-ness of this condition, facilitate physicianpatient dialogue,and thus provide the opportunity for women with vaginalatrophy to make better-informed treatment decisions.
METHODS
The VIVA survey was carried out during August 2010 byStrategyOne (London, UK). As an independent marketresearch organization, StrategyOne selected survey respon-dents from pre-recruited panels of individuals who had optedto participate in surveys via e-mail, so as to obtain a repre-sentative sample of women. No financial incentive was offered.To take part in the VIVA survey, the women were requiredto be aged 5565 years, to have reached the menopause andceased menstruating for
12 months, and to be living inGreat Britain, the United States, Canada, Sweden, Denmark,Finland, or Norway. These countries were chosen to reflectdifferences not only in health-care systems, but also in culturalattitudes and country-specific initiatives to increase patientsawareness of relevant issues (e.g. media coverage and internet-based information, such as websites and patient discussionforums), with the Scandinavian countries being perceived asmore liberal and progressive in this regard
14
 . Great Britain,the United States, and Canada were included as a representa-tive sample of English-speaking countries.This quantitative, internet-based survey used a structuredonline questionnaire to obtain basic demographic informationfrom participants, and to assess respondents’ knowledge of vaginal atrophy and sources of information and advice. Thequestions also aimed to collect information regarding womensawareness, perceptions, and experience of treatment options forvaginal atrophy. The questionnaire considered various aspectsof vaginal atrophy, which was referred to as ‘vaginal discom-fort’ and defined as dryness, itching, burning or soreness in thevagina, involuntary urination, or vaginal pain in connectionwith touching and/or intercourse. The questions used to collectinformation on vaginal atrophy, its treatment, and respondentsperceptions of the condition are presented in Table 1.Various measures were employed to ensure the quality of the data and to remove any potential bias. Potential respon-dents were asked a series of screening questions to ensureeligibility to participate in the survey. The data from therespondents were then thoroughly checked, and any nonsensi-cal responses or questionnaires which had been completed tooquickly were discounted.Data from 3520 respondents (500 participants each fromGreat Britain, the United States, Canada, Sweden, Denmarkand Finland, and 520 from Norway) were summarizeddescriptively. Results are described here for the total popula-tion, with country-specific differences in responses highlightedwhere appropriate.
RESULTSSurvey population
The demographic characteristics of the survey population aregiven in Supplementary Table 1 to be found online at http:// www.informahealthcare.com/cmt/doi/10.3109/13697137.2012.647840. The majority of women surveyed (67%) hadtheir last menstrual cycle more than 5 years previously; mostwere married (58%) and lived in cities or towns (51%). Over-all, 44% did not have a gynecologist, but this percentageshowed marked variation between different countries: themajority of respondents from Great Britain (73%) did not havea gynecologist, compared with just 15% of those in Finland.Additionally, more women in Finland (62%) than in any othersampled country had access to a female gynecologist.
Vaginal atrophy
Overall, 45% of survey respondents reported experiencing someform of vaginal symptom of menopause (Figure 1). This figureranged from 38% in Sweden to 51% in the United States. Mostwomen attributed these symptoms to conditions other than
   C   l   i  m  a  c   t  e  r   i  c   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   N  o  v  o   N  o  r   d   i  s   k   A   /   S   (   A   C   T   I   V   E   )  o  n   0   1   /   1   0   /   1   2   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .
 
Vaginal health survey Nappi and Kokot-Kierepa
38 Climacteric
one-quarter (23%) did not know. Only 2% of women consid-ered ‘vaginal atrophy’ to be a suitable term.Among the 45% of women specifically reporting vaginaldiscomfort, 83% had experienced vaginal dryness, 42% painduring intercourse, 30% involuntary urination, 27% sore-ness, 26% itching, 14% burning, and 11% pain when touch-ing the vagina. While 38% of women experiencing vaginal
Table 1
Questions included in the survey on vaginal discomfort*
Symptom occurrence, severity and effects
Which symptoms of the menopause have you experienced?If you experienced dryness, itching, burning, soreness in your vagina, or pain during intercourse, which condition(s) wouldyou think you had?If you experienced dryness, itching, burning, soreness in your vagina, or pain during intercourse, which term do you think isthe most suitable to describe this?Have you experienced vaginal discomfort since you stopped menstruating?
 For respondents who had experienced vaginal discomfort since the menopause:
 Which symptom(s) of vaginal discomfort have you experienced since you stopped menstruating?Overall, how severe would you describe the symptom(s) of vaginal discomfort you experienced?For how long have you experienced symptoms of vaginal discomfort?How concerned or not concerned are or were you about the symptoms of the menopause?Generally speaking, do you think vaginal discomfort is an acute or a chronic condition?Which word(s) or phrase(s) do you think describe(s) how a woman might feel about herself when having symptoms of vaginal discomfort?How do you think vaginal discomfort affects womens lives in general?Which area(s) of a womans life do you feel is/are negatively impacted by vaginal discomfort?
 Information sources and advice
Do you think there is enough information available about the symptoms and treatment of vaginal discomfort?From which source(s) have or would you obtain information to understand your symptoms and/or treatment options forvaginal discomfort?How do or would you feel about speaking to your doctor about vaginal discomfort?How strongly do you agree or disagree with the following? ‘My doctor did not discuss with me what it means to have a healthyvagina after menopause.
For respondents who had experienced vaginal discomfort since the menopause:
Which health-care professional(s) did you go to for treatment when you experienced vaginal discomfort?
 For respondents who had experienced vaginal discomfort since the menopause and who had consulted a health-care professional for their symptoms:
For how long did you experience the symptoms of vaginal discomfort before seeing a health-care professional?
 Treatment
Which treatment(s) are you aware of for the effective treatment of vaginal discomfort?
 For respondents who had experienced vaginal discomfort since the menopause:
Which treatment(s) have you used to treat your symptoms of vaginal discomfort?Which consequence(s) do you associate with HRT oral tablets or patches?Would you consider taking HRT oral tablets and/or patches to treat vaginal discomfort, if you knew they were effectiveand would keep your hormone levels normal?Which consequence(s) do you associate with local estrogen therapy?Would you consider taking local estrogen therapy, which is a small amount of estrogen in the form of tablets, vaginal creams,vaginal suppositories or a ring inserted into the vagina to treat vaginal discomfort, if you knew it was effective and wouldkeep your hormone levels normal?How strongly do you agree or disagree with the following? ‘I am not expecting to return to the vagina of my youth; however,I would welcome greater comfort.How strongly do you agree or disagree with the following? ‘I want to have the freedom to be the woman I want, independently of age.Note: The questions shown above are grouped according to their presentation in this article, which is not necessarily indicative of the orderin which they were asked in the survey. Respondents were able to select answers to each question from a list, with more than one answerbeing permissible in some instances. The survey used questionnaires in the local languageHRT, hormone replacement therapy*, Defined as dryness, itching, burning or soreness in the vagina, involuntary urination, or vaginal pain in connection with touching and/ or intercourse
vaginal atrophy, or did not know their cause (Figure 2). Only4% attributed the symptoms to vaginal atrophy. When askedfor the most suitable term to describe dryness, itching, burningor soreness in the vagina or pain during intercourse, 32% chosevaginal dryness, 11% selected ‘vaginal discomfort, 2% opted for ‘poor vaginal health, 2% chose ‘vaginal dysfunction, 28% thought that none of these terms were appropriate, and almost
   C   l   i  m  a  c   t  e  r   i  c   D  o  w  n   l  o  a   d  e   d   f  r  o  m    i  n   f  o  r  m  a   h  e  a   l   t   h  c  a  r  e .  c  o  m    b  y   N  o  v  o   N  o  r   d   i  s   k   A   /   S   (   A   C   T   I   V   E   )  o  n   0   1   /   1   0   /   1   2   F  o  r  p  e  r  s  o  n  a   l  u  s  e  o  n   l  y .

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