Climacteric

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Vaginal Health: Insights, Views & Attitudes (VIVA-

LATAM): results from a survey in Latin America

R. E. Nappi, N. R. de Melo, M. Martino, C. Celis-González, P. Villaseca, S.

Röhrich & S. Palacios

To cite this article: R. E. Nappi, N. R. de Melo, M. Martino, C. Celis-González, P. Villaseca, S.

Röhrich & S. Palacios (2018): Vaginal Health: Insights, Views & Attitudes (VIVA-LATAM): results
from a survey in Latin America, Climacteric, DOI: 10.1080/13697137.2018.1461826

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CLIMACTERIC
https://doi.org/10.1080/13697137.2018.1461826

ORIGINAL ARTICLE

Vaginal Health: Insights, Views & Attitudes (VIVA-LATAM): results from a survey
in Latin America
R. E. Nappia , N. R. de Melob, M. Martinoc, C. Celis-Gonz
alezd, P. Villasecae, S. Ro
€hrichf and S. Palaciosg
a
Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Department of
Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; bDepartment of Obstetrics and Gynecology, S~ao Paulo
University Medical School, S~ao Paulo, Brazil; cAsociacion de Obstetricia y Ginecologia de Rosario (ASOGIR), Rosario, Argentina; dHospital
de Ginecolog
ıa y Obstetricia No.4 “Luis Castelazo Ayala”, Mexican Institute of Social Security, Mexico City, Mexico; eDepartment of
Endocrinology, Pontificia Universidad Cat
olica de Chile, Santiago, Chile; fNovo Nordisk Health Care AG, Zurich, Switzerland;
g
Palacios Institute of Women’s Health, Madrid, Spain

ABSTRACT ARTICLE HISTORY

Objective: To investigate awareness in Latin America, knowledge of postmenopausal vaginal atrophy Received 23 February 2018
was evaluated in a sample of women from this region. Accepted 2 April 2018
Methods: A total of 2509 postmenopausal women aged 55–65 years, resident in Argentina, Brazil, Published online 8 May 2018
Chile, Colombia and Mexico, completed a structured online questionnaire.
KEYWORDS
Results: Over half the surveyed population (57%) reported experiencing symptoms of vaginal atrophy. Attitude; genitourinary
Only 6% of the overall cohort attributed symptoms of vaginal atrophy directly to the condition, and syndrome of menopause;
71% did not consider the condition to be chronic, resulting in many women not accessing effective Latin American women;
therapy. Half the women (49%) affected by vaginal atrophy had used lubricating gels and creams; 36% local estrogen therapy;
had used some form of local hormone treatment. To understand symptoms and/or treatment options menopause; survey; vaginal
for vaginal discomfort, the majority of survey participants (92%) were willing to seek advice from atrophy; vaginal health
health-care professionals; most (61%) felt/would feel comfortable talking to their doctor about this.
Conclusion: Many women in Latin America lack knowledge of postmenopausal vaginal atrophy, not
appreciating the chronic nature of the condition, and may benefit from dialog initiated by health-care
professionals to facilitate greater understanding and increased awareness of the availability of effect-
ive treatment.

Introduction with this, and to evaluate women’s experiences of the meno-

In postmenopausal women, estrogen deficiency can lead to
vaginal atrophy, symptoms of which include loss of vaginal
lubrication, as well as vaginal discomfort, itching, burning
and pain1. Vaginal atrophy can adversely affect sexual health
and quality of life; although as many as half of postmeno-
pausal women experience symptoms attributable to the con-
dition, they may not appreciate the impact of these and be
unaware that effective treatment is available2. Indeed, the
previously reported Vaginal Health: Insights, Views &
Attitudes (VIVA) survey, involving 3520 postmenopausal
women from seven countries in Europe and North America,
showed that respondents generally had little knowledge of
vaginal atrophy3–5. Notably, sociocultural factors made a sub-
stantial difference to the way in which the condition was per-
ceived by women, its effect on relationships, and the nature
of the support available from health-care teams. Regardless
of such differences, it was advocated that medical practi-
tioners should proactively initiate discussions with patients,
to improve understanding of the condition and raise aware-
ness of treatment options3. However, it was also proposed
that country-specific approaches may be required3. In line
pause and vaginal atrophy in Latin America, where women
are often concerned about the consequences menopause
can have on their sexual lives6, the VIVA-LATAM survey has
now been performed in five countries in this region.
Data from the Collaborative Group for Research of the
Climacteric in Latin America (REDLINC) have provided previ-
ous information7,8. For women in Latin America, menopause
may occur at a relatively early age and have a highly nega-
tive impact on quality of life9. Other REDLINC data, from a
study involving 7243 women aged 40–59 years resident in 11
Latin American countries10, showed a high prevalence of sex-
ual dysfunction (56.8%), as measured by the Female Sexual
Function Index, with vaginal dryness being the most import-
ant associated risk factor (odds ratio 3.86, 95% confidence
interval 3.37–4.43). Rates of sexual dysfunction varied widely
between different Latin American populations10.
Across Latin America, both within and between countries,
there are striking differences in health risks, health care and
health outcomes across society11 – women may have weak
social protection systems, and negative effects of the meno-
pause may be of particular concern in this region9.

CONTACT S. Palacios ipalacios@institutopalacios.com ~a, 9, 28009 Madrid, Spain

Instituto Palacios, Salud y Medicina de la Mujer, Calle de Antonio Acun
Supplemental data for this article can be accessed here.
ß 2018 International Menopause Society
2 R. E. NAPPI ET AL.
Information about knowledge of postmenopausal vaginal
atrophy in a sample of women resident in Argentina, Brazil,
Chile, Colombia and Mexico, as generated by the current
VIVA-LATAM survey, will be valuable in helping health-care
professionals (HCPs) to better understand prevailing situations
and attitudes. The chosen countries, including the largest in
the region (by population) and spanning the geographical
area, are intended to be representative, and the data thus
obtained may ultimately contribute to improving postmeno-
pausal care and outcomes for women across Latin America.
Methods
The current survey was conducted by Edelman Intelligence
(https://www.edelman.co.uk/) during May 2016. The survey
sample involved a total of 2509 women resident in Argentina
(n ¼ 500), Brazil (n ¼ 504), Chile (n ¼ 502), Colombia (n ¼ 503)
and Mexico (n ¼ 500) who were aged 55–65 years, had
reached menopause and ceased menstruating for
12 months. Women were enrolled from pre-recruited pan-
els of individuals with internet access who had elected to
participate in such research. In an attempt to obtain a repre-
sentative sample, recruitment quotas were applied with
regard to age and regional representation; other sociodemo-
graphic factors – marital status, level of education and
income – were monitored to ensure representative recruit-
ment. There was no financial incentive for participation.
The women completed a structured, online questionnaire,
translated from that used in the previous VIVA survey con-
ducted in North America and Europe3. The questionnaire was
translated into Portuguese for use in Brazil, and into Spanish
for use in Argentina, Chile, Colombia and Mexico.
Translations were performed by Edelman Intelligence
(London, UK) with local input, and proofed/validated by a
pharmaceutical linguist at TransPerfect (London, UK); the
translations were subsequently reviewed by two of the
authors (REN and SP) who confirmed their suitability.
The questions (Supplementary Material S1) covered a
range of areas: women’s health concerns, including meno-
pausal symptoms; experiences/perceptions of vaginal atro-
phy; sources of information and advice; as well as awareness
and understanding of treatment options. To focus on vaginal
atrophy, questions used the term ‘vaginal discomfort’ –
defined as dryness, itching, burning or soreness in the
vagina, involuntary urination, or pain in the vagina in con-
nection with touching and/or intercourse.
Given the number of questions in the survey, in the current
article, responses to selected questions are summarized
descriptively. The overall margin of error at the 95% level of
confidence was ±1.9 (± 4.4 for each individual country). Where
appropriate, statistically significant differences between groups
were determined at the 95% level of confidence via T-testing.
Results
Survey population
The demographic characteristics of the survey population are
shown in Supplementary Table S1. The majority of women
were 55–60 years of age (70%) and around half the cohort
(56%) were married or cohabiting/living as married, which, in
terms of subsequent analysis, was regarded as ‘in a
relationship’. Any other marital status response was regarded
as ‘not in a relationship’; further information relating to part-
ners for women who were single, widowed or divorced was
not captured. The majority of the cohort (97%) lived in a city,
town or suburb. Considering the women’s highest level of edu-
cation, 45% had attained a university degree or more, while
5% had not finished secondary school (or the equivalent).
Health concerns and vaginal symptoms
Nearly all the women surveyed believed good health (99%)
and quality of life (99%) to be important in helping them to
achieve happiness; the majority were concerned about the
health of their vagina (64%), incontinence (60%), and their
sexual health (51%).
Women associated the menopause with multiple symp-
toms, including hot flushes (70%) and vaginal symptoms
(68%) (Figure 1(a)). While 48% of women associated dryness,
itching, burning, soreness in the vagina or pain during inter-
course, with the menopause, only 6% attributed these symp-
toms directly to vaginal atrophy (Figure 1(b)).
Vaginal atrophy – experiences and perceptions
Since stopping menstruating, 57% of the survey population
reported experiencing vaginal discomfort. Among these, 80%
had vaginal dryness, 43% pain during intercourse, 35% itch-
ing, 28% involuntary urination, 26% burning and 6% pain
when touching the vagina. While 35% of affected women
described their symptoms as being mild, 65% considered
these to be moderate (58%) or severe (7%).
Although, overall, 71% of the women surveyed did not
know vaginal atrophy to be a chronic condition, more than
half (54%) of those who had experienced vaginal discomfort
described having symptoms for more than 1 year, and almost
one-third (30%) reported symptoms for 3 years or longer.
Women with symptoms for at least 1 year were more likely
than those with symptoms of a shorter duration to recognize
vaginal atrophy as chronic (58% vs. 22%), as were respond-
ents describing their symptoms as severe rather than moder-
ate or mild (78% vs. 40%).
Most of the women surveyed (91%) said that vaginal dis-
comfort would have a negative impact on various aspects of
life. Areas considered to be negatively affected (Figure 2)
included sexual intimacy (73%), having a loving relationship
with a partner (46%), and overall quality of life (36%).
Overall, 78% of women considered vaginal discomfort to
impact intimate relationships (including effects on sexual
intimacy and having a loving relationship with a partner).
Comparing results for women who were in a relationship
with those who were not, 63% and 50%, respectively,
reported experiencing vaginal discomfort; 68% and 59%,
respectively, described their symptoms as moderate or severe;
50% and 33%, respectively, had pain during intercourse and/
or when touching the vagina; 76% and 68%, respectively, felt

Figure 1. Knowledge of vaginal symptoms reflected by responses from survey participants (n ¼ 2509). (a) Symptoms associated with the menopause by the survey
participants. (b) Conditions thought to cause dryness, itching, burning, soreness in the vagina or pain during intercourse.
that vaginal discomfort impacted sexual intimacy. Indeed,
overall, 64% of the surveyed population considered that vagi-
nal discomfort could limit the comfort of doing what they
wanted to do, when they wanted to do it, including sex, and
56% believed the condition could also affect the sexual satis-
faction of their partner/cause him sexual problems.
Over one-third of respondents (35%) considered vaginal
discomfort to have negative consequences on women’s self-
esteem, and 78% would have welcomed greater comfort,
although they ‘were not expecting to return to the vagina of
[their] youth’.
Information sources and advice
One-third of the women (33%) believed that not enough
information was available about the symptoms and treat-
ment of vaginal discomfort. To understand symptoms and/or
treatment options, overall, 92% of survey participants had
consulted/would consult HCPs (gynecologists [81%] and
other doctors [39%]; specific data for midwives or other prac-
titioners were not captured); the corresponding figures for
CLIMACTERIC 3
online sources and printed material were 42% and 14%,
respectively.
When asked how they felt/would feel when speaking to
their doctor about vaginal discomfort, the majority of women
(61%) reported being comfortable. However, 16% of those
affected by vaginal discomfort had never sought treatment
from HCPs. In many cases, the women’s doctors had not vol-
unteered explanations of the symptoms to be expected dur-
ing menopause (38%) or discussed postmenopausal vaginal
health (45%).
Treatment
Despite the availability of effective treatment, 15% of the
women surveyed believed no effective therapy was available
for vaginal discomfort. This proportion varied according to
women’s experiences: 18% of all women who had experi-
enced vaginal atrophy, 19% of those who had tried some
form of treatment for their symptoms and 34% of those with
4 R. E. NAPPI ET AL.
Figure 2. Areas of a woman’s life felt to be negatively affected by vaginal discomfort (n ¼ 2509).
severe symptoms did not believe that any effective therapy
was available for vaginal discomfort.
However, the majority of the survey population (79%) was
aware of treatment options, mainly lubricating gels and
creams (59%) (Figure 3(a)). Other treatments of which women
were aware included vaginal hormone creams (40%), hor-
mone replacement therapy oral tablets and patches (27%),
vaginal hormone suppositories (25%), vaginal hormone tab-
lets (19%), mineral/vitamin supplements (17%) and vaginal
hormone rings (3%). Overall, 52% of women were aware of
some form of local hormonal treatment.
In line with awareness of treatment options in the overall
survey population, women who had experienced vaginal dis-
comfort were more likely to use products associated with
short-term symptom relief than they were to address the
underlying cause. Half of the affected women (49%) had
used lubricating gels and creams (Figure 3(b)), while a total
of 36% had used some form of local hormone treatment. No
differences in treatment use were apparent with regard to
women’s level of education.
Country-specific differences
Evaluation of the survey results showed women’s perceptions
and attitudes were generally consistent across the five Latin
American countries, although statistically significant differen-
ces were evident in some instances. For instance, although
98% of women from Brazil believed good heath to be
important in helping them to achieve happiness (similar to
99% for the overall population), fewer respondents in this
cohort than from other countries were concerned about the
health of their vagina (31% [64% overall]) and their sexual
health (27% [51% overall]). Nevertheless, a higher proportion
considered vaginal discomfort to have negative consequen-
ces on self-esteem (44% [35% overall]). Also, women from
Colombia were the most likely to associate the symptoms of
vaginal atrophy with a symptom of the menopause (54%
[45% overall]), with 72% being concerned with vaginal dry-
ness. Women from Chile were more likely to be concerned
about urinary incontinence than respondents from other
countries (75% [60% overall]).
Additional data showing general health concerns and
vaginal symptoms by country are reported in Supplementary
Tables S2 and S3, respectively.
Discussion
Overall, the results of this study show that health, including
vaginal health, is important for postmenopausal women in
Latin America. The majority of the cohort (92%) were willing
to seek advice from HCPs, and most (61%) felt/would feel
comfortable talking to their doctor about vaginal discomfort.
Over half the surveyed population (57%) reported experienc-
ing symptoms of vaginal atrophy (although rates of pain dur-
ing intercourse could have been underestimated as not all
the women surveyed may have been sexually active), with
potential impacts including effects on intimacy and women’s
partners. However, lack of knowledge – only 6% of VIVA-
LATAM respondents attributed symptoms of vaginal atrophy
directly to the condition, and 71% did not consider the con-
dition to be chronic – results in many women not accessing
effective therapy. By proactively raising the topic of vaginal
health during routine clinical consultations, HCPs can help
patients to understand the chronic nature of vaginal atrophy
and the treatment options that are available, thereby poten-
tially improving outcomes. Also in relation to management, it
is interesting to note that 20% and 14% of the women par-
ticipating in the VIVA-LATAM survey considered symptoms of
vaginal atrophy to result from ‘bladder infection’ and ‘thrush’,

Figure 3. Treatment for vaginal discomfort. (a) Effective treatments of which women were aware (n ¼ 2509). (b) Treatments used by women with vaginal
discomfort (n ¼ 1422). More than one option could be selected.
respectively – in some instances, preoccupation with possible
infection may hamper receipt of successful treatment.
When considering the results of this study, it should be
acknowledged that women from the countries involved are
likely to exhibit differences in their ways of life. Indeed, self-
rating indicators have previously shown huge cultural differ-
ences in heath perceptions across Latin America12, and there
is inequity in health care both between and within countries
in this region11. The current survey aimed to obtain represen-
tative samples of women from Argentina, Brazil, Chile,
Colombia and Mexico, and the ways in which vaginal atrophy
was perceived, together with women’s attitudes towards this,
were found to be generally consistent. There were some dif-
ferences. For example, fewer women from Brazil than from
other countries were concerned about the health of their
CLIMACTERIC 5
vagina (31% [64% overall]), but a higher proportion of
respondents from Brazil considered vaginal discomfort to
have negative consequences for self-esteem (44% [35% over-
all]). The data from this study thus highlight that postmeno-
pausal women are likely to benefit from increased
understanding as to the nature of, and treatment options for,
vaginal atrophy. This may be facilitated by HCPs adopting
country-specific approaches that take into account local cir-
cumstances – in Chile, there is a national program for health
care in middle-aged women that includes urogynecological
health (http://www.minsal.cl/salud-de-la-mujer/). Considering
such recommendations, differences in health-care access may
be important. When women receive hospital obstetric care in
Latin America, for up to 75%, this takes place in state-sup-
ported facilities, with constrained resources; other women
6 R. E. NAPPI ET AL.
may be able to afford better-resourced private hospitals11.
Indeed, differences in culture and in health-care systems
across the regions in which the VIVA survey has now taken
place may affect reported rates of vaginal discomfort (57%
for the current survey in Latin America vs. 45% for the VIVA
survey in North America and Europe3) and approaches to be
adopted when intending to improve outcomes – women
accessing health care in the United States and Europe gener-
ally do so by private and public routes, respectively. The
importance of identifying attitudes and behaviors in attempts
to overcome barriers to the diagnosis, management and
treatment of vaginal atrophy has been highlighted
previously13.
Previously published data from Latin America have also
provided information about treatment. Of 6731 women sur-
veyed in 11 countries, 48.8% had previously used, but subse-
quently abandoned, oral or transdermal hormone therapy14,
while a survey of 540 women in Chile showed a lower rate of
hormone replacement therapy use with lower socioeconomic
status15. In addition, 86.8% of 1837 surveyed gynecologists
had prescribed non-hormonal therapies16. However, non-
hormonal, over-the-counter products may provide short-term
symptom relief without addressing the underlying cause. In
our current survey, lubricating gels and creams had been
used by half (49%) of the women affected by vaginal atrophy.
Thirty-six percent had used local hormone treatment. There is
opportunity for management to enhance outcomes.
It is appropriate to consider the strengths and weaknesses
of the current survey. While the enrollment process attempted
to obtain representative samples of women from each country,
taking into account prevailing sociodemographic factors and
applying recruitment quotas, given the nature of the survey,
the sample was restricted to women with internet access. This
facilitated data collection and enabled participation with rela-
tive anonymity, but inevitably influenced the demographic
characteristics of the cohort. Most study participants (97%)
lived in a city, town or suburb. Based on discussion of the val-
idity of a previous Latin American survey, this may not be a
serious confounding factor as most women live in urban
areas7, but it may have resulted in under-representation of
women from rural locations at a country level. The prerequisite
for internet access may also have resulted in disproportionate
representation of more highly educated individuals, which
could have influenced routes of access to health care.
However, no differences in treatment use were apparent with
regard to women’s level of education.
Despite its limitations, the VIVA-LATAM study shows the
need for improved management of vaginal atrophy in post-
menopausal women in Latin America. This should be available
for all women, regardless of demography. Indeed, previous
research involving isolated communities has shown postmeno-
pausal Quechua and Zenu
women, from Peru
and Colombia,
respectively, to have particularly prevalent and intense uro-
genital symptoms17. However, in another study performed in
Mexico, urogenital symptoms were cited as the primary
motive for initial climacteric consultation by only 9.3% of
women with natural menopause, despite significantly higher
Menopause Rating Scale scores for vaginal dryness being
apparent in climacteric than late-reproductive stage women18.
The data from the current study confirm evidence from
other regions of the world, where, despite recent efforts, post-
menopausal vaginal atrophy continues to be under-recognized
and under-treated, and enhanced communication between
women and HCPs should be actively promoted6,19–23.
However, women may not generally be familiar or comfortable
with the term ‘vaginal atrophy’24. In 2013, a consensus confer-
ence organized by the International Society for the Study of
Women's Sexual Health and the North American Menopause
Society agreed use of the term ‘genitourinary syndrome of
menopause’ in relation to the symptomatology of the genito-
urinary tract associated with menopause25. This comprises the
whole span of symptoms and may resonate better for patients
than talking about vaginal atrophy; it may thus be helpful for
improving communication.
In conclusion, in line with data obtained from women else-
where in the world, the results of the current survey suggest
that many women in Latin America lack knowledge of postmen-
opausal vaginal atrophy, not appreciating the chronic nature of
the condition, and may thus benefit from HCP-initiated dialog
to facilitate greater understanding and increased awareness of
the availability of effective treatment. Such an approach could
be coupled with consumer-oriented awareness programs.
Country-specific approaches may be appropriate.
Acknowledgements
Medical writing support for this manuscript was provided by Andy
Lockley of Bioscript Medical, UK, and funded by Novo Nordisk Health
Care AG, Switzerland.
Conflict of interest Rossella Elena Nappi has a financial relationship
(lecturer, member of advisory boards and/or consultant) with Bayer
HealthCare, Endoceutics, Gedeon Richter, MSD, Novo Nordisk, Pfizer,
Shionogi, Teva and Zambon SpA. Nilson Roberto de Melo, Mabel Martino
and Cuauht
emoc Celis-Gonz
alez have no conflicts of interest. Paulina
Villaseca has participated in advisory boards for Amgen and Novo
Nordisk. Sebastian Ro €hrich is an employee of Novo Nordisk. Santiago
Palacios has been a symposium speaker or advisory board member for
Abbott, Amgen, Bioiberica, Ferrer, Gedeon Richter, GSK, Mylan, Novo
Nordisk, Pfizer, S
er
elys Pharma, Servier and Shionogi; he has also
received research grants and/or consulting fees from Amgen, Bayer,
Gedeon Richter, MSD, Pfizer, Procare, Servier and Syneron Candela.
Source of funding The VIVA-LATAM survey was commissioned by
Novo Nordisk Health Care AG, Switzerland.
ORCID
R. E. Nappi http://orcid.org/0000-0002-5216-9882
S. Palacios http://orcid.org/0000-0003-2229-1200
References
1. Archer DF. Efficacy and tolerability of local estrogen therapy for
urogenital atrophy. Menopause 2010;17:194–203
2. Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health
and quality of life at postmenopause. Climacteric 2014;17:3–9

3. Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views &
Attitudes (VIVA) – results from an international survey. Climacteric
2012;15:36–44
4. Simon JA, Kokot-Kierepa M, Goldstein J, Nappi RE. Vaginal health
in the United States: results from the Vaginal Health: Insights,
Views & Attitudes survey. Menopause 2013;20:1043–8
5. Frank SM, Ziegler C, Kokot-Kierepa M, Maamari R, Nappi RE.
Vaginal Health: Insights, Views & Attitudes (VIVA) survey –
Canadian cohort. Menopause Int 2013;19:20–7
6. Sturdee DW, Panay N. Recommendations for the management of
postmenopausal vaginal atrophy. Climacteric 2010;13:509–22
7. Bl€
umel JE, Chedraui P, Calle A, et al. Age at menopause in Latin
America. Menopause 2006;13:706–12
8. Chedraui P, Bl€ umel JE, Baro
n G, et al. Impaired quality of life
among middle aged women: a multicentre Latin American study.
Maturitas 2008;61:323–9
9. Palacios S, Henderson VW, Siseles N, Tan D, Villaseca P. Age of
menopause and impact of climacteric symptoms by geographical
region. Climacteric 2010;13:419–28
10. Bl€
umel JE, Chedraui P, Baro
n G, Collaborative Group for Research
of the Climacteric in Latin America (REDLINC), et al. Sexual dys-
function in middle-aged women: a multicenter Latin American
study using the Female Sexual Function Index. Menopause
2009;16:1139–48
11. Beliz
an JM, Cafferata LM, Beliz
an M, et al. Health inequality in
Latin America. Lancet 2007;370:1599–600
12. Lora E. Health perceptions in Latin America. Health Policy Plan
2012;27:555–69
13. Castelo-Branco C, Biglia N, Nappi RE, Schwenkhagen A, Palacios S.
Characteristics of post-menopausal women with genitourinary syn-
drome of menopause: implications for vulvovaginal atrophy diag-
nosis and treatment selection. Maturitas 2015;81:462–9
14. Bl€
umel JE, Chedraui P, Baro
n G, Collaborative Group for Research
of the Climacteric in Latin America (REDLINC), et al. A multicentric
study regarding the use of hormone therapy during female mid-
age (REDLINC VI). Climacteric 2014;17:433–41
15. Bl€
umel JE, Castelo-Branco C, Riquelme R, et al. Use of hormone
replacement therapy among Chilean women: a comparison
between socioeconomic levels. Menopause 2002;9:377–80
CLIMACTERIC 7
16. Danckers L, Bl€umel JE, Witis S, Collaborative Group for Research of
the Climacteric in Latin America (REDLINC), et al. Personal and pro-
fessional use of menopausal hormone therapy among gynecolo-
gists: a multinational study (REDLINC VII). Maturitas 2016;87:67–71
17. Ojeda E, Monterrosa A, Bl€ umel JE, Escobar-Lo
pez J, Chedraui P.
Severe menopausal symptoms in mid-aged Latin American women
can be related to their indigenous ethnic component. Climacteric
2011;14:157–63
18. Legorreta D, Montan ~ o JA, Hern
andez I, Salinas C, Hern
andez-
Bueno JA. AMEC Research Committee. Age at menopause, motives
for consultation and symptoms reported by 40–59-year-old
Mexican women. Climacteric 2013;16:417–25
19. Nappi RE, Kokot-Kierepa M. Women’s voices in the menopause:
results from an international survey on vaginal atrophy. Maturitas
2010;67:233–8
20. Nappi RE, Kingsberg S, Maamari R, Simon J. The CLOSER
(CLarifying Vaginal Atrophy’s Impact On SEx and Relationships)
survey: implications of vaginal discomfort in postmenopausal
women and in male partners. J Sex Med 2013;10:2232–41
21. Nappi RE, Palacios S, Particco M, Panay N. The REVIVE (REal
Women’s VIews of Treatment Options for Menopausal Vaginal
ChangEs) survey in Europe: country-specific comparisons of post-
menopausal women’s perceptions, experiences and needs.
Maturitas 2016;91:81–90
22. North American Menopause Society. The 2017 hormone therapy
position statement of The North American Menopause Society.
Menopause 2017;24:728–53
23. Krychman M, Graham S, Bernick B, Mirkin S, Kingsberg SA. The
women's EMPOWER survey: women's knowledge and awareness of
treatment options for vulvar and vaginal atrophy remains inad-
equate. J Sex Med 2017;14:425–33
24. Parish SJ, Nappi RE, Krychman ML, et al. Impact of vulvovaginal
health on postmenopausal women: a review of surveys on symp-
toms of vulvovaginal atrophy. Int J Womens Health 2013;5:437–47
25. Portman DJ, Gass ML. Vulvovaginal Atrophy Terminology
Consensus Conference Panel. Genitourinary syndrome of meno-
pause: new terminology for vulvovaginal atrophy from the
International Society for the Study of Women's Sexual Health and
The North American Menopause Society. Climacteric 2014;
17:557–63