GSM has been shown to negatively impact daily living, sexuality, relationships, and QoL; as demonstrated in various surveys.12-15 The international VIVA (Vaginal health: Insights, Views & Attitudes) survey involved 3,520 postmenopausal women aged 55 to 65 years from Great Britain, the United States, Finland, Norway, Denmark, Canada, and Sweden.12 Authors found that 45% of women experienced vaginal symptoms, and 32% never sought help from a gynecologist. The majority of women (75%) indicated that vaginal atrophy negatively impacted their lives, especially sexual intimacy (64%), loving relationship with a partner (32%), overall QoL (32%), feeling healthy (21%), and feeling attractive (21%). Similarly, the CLOSER (Clarifying Vaginal Atrophy's Impact On SEx and Relationships) survey included 4,100 women, between 55 and 65 years with a history of vaginal atrophy, and 4,100 men from 9 countries (United Kingdom, Italy, Canada, the United States, Finland, Denmark, Norway, Sweden, and France).13 Main effects of vaginal atrophy were avoiding intimacy (62% of women), fewer sexual encounters (58%), less satisfying sex (49%), and putting off having sex (35%). Painful sex and reduced sexual desire were considered causes of intimacy avoidance in 55% and 46% of women, respectively. The REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs (REVIVE) survey involved 3,046 postmenopausal women from the United States with symptoms of vulvar and vaginal atrophy (mainly dryness, dyspareunia, and irritation).14 Their VVA symptoms negatively impacted enjoyment of sex (62%), sexual spontaneity (59%), ability to be intimate (58%), relationship with their partner (48%), sleep (24%), overall enjoyment of life (23%), and temperament (23%). The 12-week SMART-3 study (Selective estrogen Menopause And Response to Therapy 3) survey involved 664 postmenopausal women between 45 and 60 years of age with at least 1 moderate-to-severely bothersome vulvar-vaginal symptom (dryness, itching/irritation, or pain with intercourse).15 Authors evaluated the association between VVA endpoints and the sexual function domain of the Menopause-specific Quality of Life (MENQOL) questionnaire. The VVA symptoms were strongly related to MENQOL scores. In fact, results showed that a 1-point improvement in VVA vaginal symptoms (such as a reduction in severity) was significantly associated with changes in MENQOL score. The authors stated that clinicians can improve QoL related to sexual functioning by managing GSM symptoms.
The results from our present study (by using the validated DIVA questionnaire) are in concordance with the literature. Vaginal symptoms impacted the well-being, functioning, and QoL of our cohort of postmenopausal women from Spain. Greatest impacts were on sexual functioning, self-perception, and body image domain scales. Notably, sexually active women felt that their sexual functioning was affected by vaginal symptoms. It is well known that staying sexually active after menopause is important for overall well-being, and key for successful aging.4,19,20 Moreover, an association between sexual function and QoL has been demonstrated in various studies.14,15
Our results with the DIVA questionnaire also revealed that vaginal symptoms have a minor impact on the activities of daily living and the emotional well-being domain scales. Analyzing the domain scales related to the activities of daily living, they were noted to be mostly related to general aspects (not only to GSM), such as physical appearance due to the presence of hot flashes, or work activity, among others. In addition, the women may have misidentified emotional well-being status with their body image and self-perception, as many postmenopausal women assume vaginal symptoms to be factors associated with age.
Interestingly, all of the subdomains of the DIVA questionnaire (activities of daily living, emotional well-being, sexual functioning, and self-perception and body image) were consistently rated significantly higher in women with GSM than in those without GSM. This may translate into a relationship between GSM and the QoL of postmenopausal women, in line with various surveys and investigations in which GSM has been shown to produce a negative impact on activities of daily living, self-esteem, sex life, marriage or relationships, social life, and overall QoL.4 This finding is of particular clinical relevance because women diagnosed with GSM should be treated: not only to solve their vaginal problems, but, more importantly, to improve their self-esteem, sexual and emotional well-being, and various other aspects of their QoL.4 Treatment with long-acting vaginal moisturizers or low-dose vaginal estrogen has been shown to achieve a significant improvement in sexual health and QoL.5 One-point differences in sexual functioning and self-perception domain scales are relevant in this population of middle-aged and older women, in which QoL gains particular importance.
On the contrary, the GENISSE study also revealed important issues that need to be taken into account in the diagnosis and management of GSM.16 Approximately 70% of postmenopausal women seeking a gynecologist's opinion are ultimately diagnosed with GSM. Only 40% of postmenopausal women referred to a gynecologist had a prior diagnosis. The study also showed that GSM goes undetected in the population, as diagnosed when visiting a gynecologist during a routine check-up. This is in concordance with other studies reported previously.9,12,21 Women do not correlate this symptomatology with a decrease in estrogen and sexual steroids (ie., a chronic condition), but they consider it to be a result of the natural aging process. Indeed, only approximately 1 in 4 women experiencing GSM symptoms seeks medical assistance.22 Altogether, these results highlight the importance of adequate diagnosis and management of GSM for maintaining the well-being and QoL of women in this stage of life.
It is important for gynecologists, nurse practitioners, and primary care doctors to be aware of the major impact of this syndrome on well-being and QoL of postmenopausal women. They should routinely assess perimenopausal and postmenopausal women for GSM and sexual activities. Because of their specialization in the female genital tract and reproductive health, gynecologists are the doctors who most frequently deal with patients’ sexual problems. Unfortunately, sexual issues are usually avoided in medical consultations.23 Gynecologists, nurse practitioners, and primary care doctors should help their patients understand that GSM is a chronic condition that requires proper management and which will have an integral effect on postmenopausal woman. The use of validated questionnaires (such as the DIVA) can guide health professionals as they treat, manage, and monitor these women.
One limitation of the study was that gynecologists mainly came from private practices (95%). Although the information shown in the present study is relevant, by including postmenopausal women who were attended in public healthcare centers could strengthen the conclusions. In fact, we believe that the prevalence of women with GSM in clinical practice might be higher than reported. Another limitation of the study was the absence of a validation study for the Spanish version of DIVA questionnaire to provide reliability for the results obtained in the Spanish population.
Vaginal symptoms impact the well-being, functioning, and QoL of postmenopausal women, especially their sexual function, self-perception, and body image. This impact is significantly higher in women with GSM. Up to 70% of postmenopausal women are affected by GSM: a condition that can be adequately managed with available treatments. It is highly likely that treating their GSM would result in an improvement of the affected women's QoL. This needs to be proven in further prospective studies involving larger cohorts of postmenopausal women and different treatment groups.
Additional participants in the GENISSE study were as follows: M.F. Oltra (Alicante), E.M. Contreras (Cádiz), R. León (Cádiz), C. González (Sevilla), M.I. Massé (Sevilla), E. Flores (Sevilla), R. Rodríguez (Orense), I. Lago (Pontevedra), A.M. González (Vigo), O. Valenzuela (Vigo), M. Villegas (Barcelona), A. Jordán (Barcelona), B. Meneses (Barcelona), I. Núñez (Barcelona), C.J. Pace (Barcelona), P. Beroiz (Barcelona), A. Martí (Barcelona), J.G. Hernández (Santa Cruz de Tenerife), L. González (Santa Cruz de Tenerife), M. Muñoz (Barcelona), J.R. Méndez (Barcelona), S. González (Barcelona), V. Rayo (Barcelona), M. Amorós (Barcelona), J.R. Rodríguez (Barcelona), C. Pedrosa (Granada), R. Herrera (Málaga), J. García (Málaga), R. Laza (Málaga), M.C. Rodríguez (Granada), A. Jarque (León), J.L. Solís (Oviedo), L. Vior (Oviedo), C.M. Rodríguez (Asturias), J.V. Carmona (Valencia), J. Server (Valencia), M. González (Valencia), L.J. Matute (Valencia), F. Ridocci (Valencia), R.V. García (Valencia), J. Moro (Salamanca), C.E. García (Zamora), M.J. Velasco (Ávila), A. Martín (Burgos), J.I. González (Valladolid), J. Velasco (Valladolid), C. Oliva (Castellón), A. Estrada (Valencia), D. Mares (Valencia), F. Ruiz (Valencia), C. Vignardi (Madrid), M.A. Martínez (Madrid), J. Lázaro (Madrid), A. Palacín (Madrid), L. San Frutos (Madrid), J.A. Navas (Córdoba), J.J. Hijona (Jaén), E. Velasco (Córdoba), M. Pérez (Lugo), M.J. Carballo (La Coruña), C. González (La Coruña), G. Tejada (Albacete), L. Sánchez (Ciudad Real), C. Martín (Toledo), M. Rey (Islas Baleares), V.H. Chávez (Islas Baleares), M.C. González (Madrid), A.R. Masero (Madrid), I. Ramírez (Madrid), C. Martín-Ondarza (Madrid), E. Vizcaíno (Madrid), N. Ros (Tarragona), A. Calvo (Lérida), J.C. Riera (Gerona), J. Salinas (Tarragona), F.R. Blanco (Badajoz), J.A. Sánchez (Badajoz), A. Monrobel (Cáceres), S. Escudero (La Rioja), A. López (Huesca), M.P. del Tiempo (Zaragoza), C.J. Elorriaga (Zaragoza), C. Ceballos (Cantabria), J. Oraa (Vizcaya), F. Mozo (Vizcaya), B. Otero (Vizcaya), T.M. Diaz (Vizcaya), S. Andreu (Madrid), L. Almarza (Madrid), R. Rodríguez (Guadalajara), M. Puch (Madrid), A. Hernández (Madrid), J. de la Fuente (Madrid), M. Ferrero (Barcelona), A. Reus (Barcelona), M. Guinot (Barcelona), M. Muñoz (Barcelona), A. Bernad (Barcelona), A. Torrent (Barcelona), V. Turrado (Barcelona), I. Etxabe (Guipúzcoa), I. Fernández (Navarra), M. Martínez (Álava), M.C. Castro (Murcia), J. Rodríguez (Alicante), C. González (Alicante), V. M. Lago (Murcia), R. Lorente (Alicante), M.A. Nieto (Las Palmas), M. Sosa (Las Palmas), M. Montero (Huelva), M.M. Falcón (Sevilla), A. Polo (Sevilla), S. Cruz (Madrid), and M. Rius (Barcelona).
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Keywords:© 2018 by The North American Menopause Society.
Functioning; Genitourinary Syndrome of menopause; Postmenopausal; Quality of life; Well-being