Vaginal Health: Insights,Views & Attitudes (VIVA) survey - Canadian cohort

Introduction

The transition to menopause is characterized by a marked decline in ovarian function. ¹ In addition to vasomotor symptoms (e.g. hot flushes, night sweats), osteoporosis and urogenital atrophy ² are common consequences of reduced endogenous estrogen levels. While vasomotor symptoms eventually subside, symptoms of urogenital atrophy tend to become worse over time.^3,4 These symptoms include vaginal discomfort, dryness, itching, burning and dyspareunia (pain associated with sexual activity); for some women, these are simply annoying, others find them debilitating. ¹ In addition to the negative impact on genital function, estrogen deficiency can also affect urinary function, as evidenced by symptoms such as urinary frequency, urgency, nocturia, incontinence and recurrent urinary tract infections. ⁵

Objective changes and subjective complaints are present in up to half of all postmenopausal women, ⁶ who typically present with symptoms of vaginal dryness. ⁷ Atrophic changes have been reported to be significantly associated with a global indication of female sexual dysfunction, as well as with difficulties relating to sexual desire, arousal and orgasm. ⁸ Menopause may thus cause considerable difficulties for women and their partners, ⁹ but only around 25% of women experiencing symptoms of urogenital atrophy seek medical help.^6,10

Personal anil cultural reluctance to discuss intimate matters with a medical professional may be a consequence of taboos regarding sexual organs and may deter women of all ages from seeking help.^11,12 Results from an international survey demonstrated that embarrassment may prevent postmenopausal women with vaginal atrophy from discussing this with a healthcare professional (HCP): 63% of the women who had experienced vaginal discomfort had never been prescribed treatment for the condition and less than half the women surveyed were aware of the availability of local treatment for menopause-related vaginal discomfort. ^{1 2} Indeed, most postmenopausal women are unlikely to report symptoms of urogenital aging to their physician unless directly questioned, and often suffer in silence. ^{1 3} Women need to be asked about their symptoms, ¹³ and providing them with the opportunity to discuss sexual problems is an essential aspect of health care. ¹⁴ However, the majority of women (70%) claim that their Util’s rarely or never raise matters such as vaginal dryness. ⁶ Thus, it appears that both patients and HCPs may attribute the symptoms of vaginal atrophy to a natural and inevitable part of the aging process. ⁶

Because vaginal atrophy is a chronic but treatable condition, medical practitioners should strive to detect symptoms early so that appropriate treatment may be initiated. ⁶ Local estrogen therapy (LET) refers to vaginal estrogen therapy that does not lead to significant systemic absorption. ¹⁵ For the treatment of urogenital atrophy only, LET is generally recommended;^6,13,15 treatment should be started early and continued for as long as women experience troublesome symptoms. ⁶ Systemic hormone replacement therapy (HRT) (estrogen alone or in combination with progestogen) refers to oral, transdermal and intrauterine hormonal treatments that result in significant absorption into the bloodstream. ¹⁵ Restoration of urogenital physiology and symptomatic relief can be achieved with systemic HRT, ⁶ but due to the concerns regarding potential adverse effects with long-term systemic exogenous estrogen, it is now widely recommended that the lowest effective dose of hormone therapy should be used for the shortest possible time with systemic HRT.^15,16 Although HCPs may assume that women taking systemic HRT will not experience symptoms of vagina, atrophy, up to 40% of women taking oral hormone replacement experience persistent vaginal dryness. ^{1 3} The Canadian Consensus Conference on Menopause ¹³ has highlighted that systemic HRT alone may not be sufficient to treat the symptoms of urogenital aging; if systemic HRT is prescribed only to treat the symptoms of vaginal atrophy, then vaginal estrogen therapy is more appropriate. For those symptomatic women who use systemic HRT for its other benefits, additional vaginal estrogen therapy may be needed. ¹³ Patient preference should be considered with regard to treatment, ⁶ and an individualized approach is required. ¹⁷

Nappi and Kokot-Kierepa ¹² recently described an international survey involving interviews with 4246 women, aged 55-65 sears and living in Sweden, Finland, the UK, the USA or Canada. Thirty-nine percent of postmenopausal women in the cohort reported symptoms of vaginal atrophy, ¹² which was similar to previous findings in American women from different ethnic backgrounds. ¹⁸ The prevalence of vaginal atrophy varied between countries, from 34% in Canada to 43% in Finland and the USA. ¹² The majority (77%) of the interviewees believed that women were uncomfortable discussing vaginal atrophy and, overall, 42% of women were unaware of the availability of local treatment for this condition. ¹² The Vaginal Health: Insights, Views & Attitudes (VIVA) survey was later initiated in Europe and North America to further explore women’s knowledge of, and attitudes towards, vaginal health (specifically vaginal atrophy), to increase awareness of this condition and to facilitate physician-patient dialogue. ^{1 9}

The current article focuses on the main results from Canadian women in the VIVA survey, and highlights differences and similarities between the women in Canada and the overall survey population.

Materials and methods

The methodology and specifics of the questionnaire used for the VIVA survey have been described previously. ¹⁹ However, in brief, survey respondents were selected from pre-recruited panels of individuals who had chosen to participate in surveys via email. Women were not offered any financial incentives.

A structured online questionnaire in the local language was used, which collected basic demographic data, and information regarding knowledge of vaginal atrophy, sources of information and advice and awareness, perceptions, and experience of treatment options for vaginal atrophy. In the questionnaire, vaginal atrophy was referred to as ‘vaginal discomfort’ and was defined as dryness, itching, burning or soreness in the vagina, involuntary urination, or pain in connection with touching and or intercourse.

To participate in the survey, women were required to be aged 55-65 years; to have reached the menopause and ceased menstruating for ≥12 months; and to be living in the UK, the USA, Canada, Sweden, Denmark, Finland or Norway The countries were chosen to reflect any differences in health-care systems and in cultural attitudes, as well as country-specific initiatives to increase patients’ awareness of issues surrounding vaginal atrophy. The Scandinavian countries were perceived as more liberal and progressive with regard to sexual health. ¹¹ The UK, the USA and Canada were included as a representative sample of English-speaking countries (although French-speaking women were also included in the Canadian cohort). Each country contributed 500 participants, except Norway, which contributed 520 (total n 3520 respondents). A series of screening questions were asked, to ensure women’s eligibility to participate in the survey. The data were then carefully scrutinized, and non-sensical responses or questionnaires that had been completed too quickly were excluded.

The VIVA survey was a quantitative market research survey carried out in accordance with the usual ethics principles lor such research. Women were informed about the research purposes of the survey, and their participation was voluntary and fully anonymous.

Data were summarized descriptively for the total population, and the results of the full survey, highlighting differences between countries have been published previously. ¹⁹ The current article reports the detailed findings from Canadian women.

Results

Survey population

The demographic characteristics of the survey population from Canada are shown in Table 1. Equal numbers of women were aged 55-59 and 60-65 years. The majority (73%) had their last menstrual cycle more than five years previously, were married (57%) and lived in cities or towns (64%). Most women (60%) did not have a gynaecologist.

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Table 1

Demographic characteristics (500 Canadian women)

Demographic characteristics
Time since menopause (%)
1 - 3 years	13
4-5 years	13
>5 years	73
Unknown	1
Marital status (%)
Married	57
Co-habiting/living as married	10
Single	11
Widowed	7
Divorced	16
Location (%)
City or town	64
Suburbs	14
Rural area	21
Physician (%)
Female	43
Male	56
Don’t have one	2
Gynaecologist (%)
Female	16
Male	25
Don’t have one	60

Vaginal atrophy

Almost half of the postmenopausal women surveyed in Canada (48%) had experienced vaginal discomfort since they had stopped menstruating. The most common symptom among those women was vaginal dryness (88%), followed by pain during intercourse (49%), involuntary urination (37%), vaginal itching (29%), vaginal soreness (19%), vaginal burning (18%) and pain when touching the vagina (13%) (Figure 1 OPEN IN VIEWER

Figure 1

Symptoms of vaginal atrophy experienced by the survey participants (n - 239)

). Nearly half the women (46%) described their symptoms as ‘moderate,’ while 40% considered them as ‘mild’ and 13% as ‘severe’. Most sufferers (61%) considered vaginal atrophy to be a chronic condition, whereas only 20% of non-sufferers believed that vaginal atrophy was a chronic condition, while two-thirds (65%) did not know whether it was chronic or acute. Notably, 77% of sufferers had experienced symptoms of vaginal atrophy for a year or more, anil over half (56%) for three years or longer (Figure 2).

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Figure 2

Length of time for which symptoms of vaginal atrophy had been experienced (n = 239)

When asked which condition they thought they hail it they were to experience dryness, itching, burning, soreness in the vagina or pain during intercourse, 42% of Canadian women identified this as ‘a symptom of menopause’, whereas 7% attributed the symptoms specifically to vaginal atrophy (Figure 3).

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Figure 3

Conditions thought to cause dryness, itching, burning or soreness in vagina, or pain during intercourse ( n = 500)

When asked for the most suitable term to describe dryness, itching, burning, soreness in the vagina or pain during intercourse, 32% of the survey population chose vaginal dryness, 11% vaginal discomfort, 4% vaginal dysfunction, 3% poor vaginal health, 22% none of those options and 23% did not know. Six percent considered ‘vaginal atrophy’ to be the most suitable term.

Of the (Canadian women surveyed, 46% of respondents had concerns about vaginal dryness, with 44% being concerned about involuntary urination, .32% about vaginal pain in connection with touching and or intercourse, 26% about vaginal soreness, 2.3% about vaginal itching and 22% about vaginal burning.

When asked which words or phrases described how a woman might feel about herself when having symptoms of vaginal discomfort, the most common responses were: ‘less sexual’ (6.3%), ‘ageing’ (50%), ‘complicates relationship with partner’ (50%), ‘embarrassed’ (36%) and ‘less spontaneous’ (35%).

Eighty two percent of women sun-eyed felt that vaginal atrophy would have a negative impact on various aspects of their lives. Sexual Intimacy stood out as most likely to tie alter ted (chosen by 72% of respondents), followed by ‘having a loving relationship with a partner’ (39%), ‘overall quality of lite’ (30%), ‘feeling healthy’ (26%) anil ‘feeling attractive’ (21%) (Figure 4) When asked how they thought that vaginal atrophy affected women’s lives in general, 66% of respondents felt that vaginal discomfort had negative consequences on their sex life, 43% that it had negative consequences on marriage or relationships, 33% that it made them feel old, 30% that it had negative consequences on self-esteem, 27% that it lowered their quality of life and 1.3% that it had negative consequences on social life.

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Figure 4

Areas of a woman ’ s life felt to be negatively impacted by vaginal discomfort ( n 500)

I he majority of women (60%) agreed that vaginal atrophy could limit their comfort of doing what they wanted to do. when they wanted to do it, including sex; in addition, over half of the women surveyed (54%) believed that vaginal discomfort could also affect the sexual satisfaction of their partner, cause him sexual problems.

Information sources and advice

less than halt the survey population (42%) considered that enough information was available about the symptoms and treatment of vaginal discomfort. Most postmenopausal women in Canada (78%) said that they had turned/would turn to their HCP (69% primary care physician, 34% gynaecologist) to obtain information to understand their symptoms and treatment options for vaginal atrophy, while 54% said that they had used would use websites and blogs; only 18% had turned/would turn to family and friends.

More women would talk to their HCP about vaginal atrophy than to friends and family (82% versus 49%) and the majority of women (71%) said that their mother never spoke to them about what to expect during menopause.

While 60% of the survey participants said that they would feel comfortable discussing vaginal atrophy with their doctor, 37% would not raise the subject or hesitate to do so; only around one-third (36%) said that they would speak to their doctor if they developed new symptoms and 20% said that they would try self-treatment before seeing a doctor. Almost two-thirds of the survey population (59%) claimed that their doctor had not raised the topic of postmenopausal vaginal health.

When asked who they would talk to about vaginal discomfort (if anybody), 72% and .30% of women in Canada indicated that they would turn to their primary care physician or gynaecologist, respectively. Similarly, if they were to experience symptoms of vaginal atrophy. 51% of women indicated that they would see their primary care physician, while 42% would see their gynaecologist. While the majority of women surveyed in Canada who hail actually experienced vaginal atrophy (n = 239) sought the assistance of a HCP (66%), a considerable proportion (34%) did not (Figure 5). Primary care physicians were most commonly consulted (40%); only 20% of women who experienced symptoms of vaginal atrophy went to a gynaecologist for treatment. Over half the women surveyed (53%) said that they would be more likely to talk to a female doctor or nurse about vaginal atrophy than a male one. Among the women who had sought the assistance of a HCP for symptoms of vaginal atrophy (n 157), one-third (32%), waited more than one year before seeing a HCP, while an additional 20% said that they had waited between six months and one year.

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Figure 5

Health-care professionals consulted for treatment by women who had experienced vaginal atrophy ( n = 239)

Treatment

When asked to identify treatments of which they were aware for the effective treatment of vaginal atrophy, women were most aware of ‘over-the-counter’ (OTC) treatments, with 68% being aware of lubricating gels and creams.

Two-thirds (62%) of survey participants in Canada were aware of hormone-related treatments. Systemic HR I oral tablets and patches (45%) and vaginal hormone creams (44%), had the highest awareness in this category. Only 17% and 9 were aware of vaginal hormone tablets anil vaginal hormone ring treatment, respectively.

Among the 239 survey participants who had experienced vaginal atrophy since they had stopped menstruating, over half (58%) had tried lubricating gels and creams to treat their symptoms, 25% reported using systemic HR f oral tablets or patches, 17% vaginal hormone creams, 12% mineral/vitamin supplements (OTC products for symptom relief), 6% vaginal hormone tablets, 5% vaginal hormone suppositories and 1% vaginal hormone ring; 26% reported using none of those treatment options (Figure 6). Women in Canada demonstrated hesitancy when it came to considering systemic HRT, with only 32% indicating that they would use HRT oral tablets and/or patches if they knew that those were effective treatments for vaginal discomfort and that they maintained normal hormone levels. Half of the respondents (48%) said that they would not consider those treatments and an additional 20% were undecided.

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Figure 6

Treatments used by women with vaginal atrophy ( n = 239)

When asked about perceptions regarding systemic HR I oral tablets and/or patches, 52% said that they associated the treatment with an increased risk of breast cancer and 46% reported concerns relating to increased risk of blood clot or stroke. Positive associations reported included slower aging (20%), increased interest in sex (19%) and feeling more energetic (19%). Overall, 61% had negative associations and 31% had positive associations.

Compared with systemic HRT, more women in Canada would consider 11.1 (i.e. vaginal tablets, vaginal creams, vaginal suppositories or vaginal ring) if they knew that this was effective for vaginal discomfort and capable of maintaining normal hormone levels. Forty-three percent of the survey participants would consider these treatments, with vaginal creams (26%) or vaginal tablets (25%) being the forms preferred by most women. Twenty-four percent were undecided and 34% would not consider such treatment.

When asked about perceptions regarding LET. 31% of survey participants said that they associated this with an increased risk of developing breast cancer and 24% reported concerns relating to increased risk of developing a blood clot or stroke. Positive associations reported included increased interest in sex (16%), slower aging (15%) and feeling more energetic (13%). Overall, 35% had negative associations and 23% had positive associations.

The postmenopausal women surveyed in Canada were generally accepting of their vaginal changes. The majority of the survey population (65%) did not expect to return to the vagina of their youth, but would welcome greater comfort.

Discussion

The VIVA survey findings from Canada indicate that women are most likely to associate menopause with hot flushes, night sweats and disrupted sleep, but that they are also aware of vaginal-related symptoms. Concerns surrounding the menopause resolved primarily around weight gain and disrupted sleep, but more than 50% of women reported symptoms of vaginal atrophy as a cause for concern.

Although a chronic condition, vaginal atrophy is treatable, but most postmenopausal women in the Canadian VIVA sample did not directly link the symptoms to the condition. Only 7% attributed symptoms to vaginal atrophy (which is comparable with 4% in the full VIVA survey; ¹⁹ consequently, effective treatment may not be initiated. However, it should be noted that although most women did not relate urogenital symptoms specifically to an entity they called ‘vaginal atrophy’, 42% of women understood that these symptoms were menopause related.

Approximately halt of women (48%) in this cohort from Canada had experienced vaginal discomfort since they stopped menstruating, with vaginal dryness being the most common symptom (described by 88% of symptomatic respondents); these findings are similar to those from the full VIVA survey, where 45% of survey respondents reported vaginal discomfort, most commonly vaginal dryness (83% of symptomatic respondents). ¹⁹ In a recent analysis of data from the US-based Women’s Health Initiative (Will), ²⁰ 69% of subjects were reported to have vaginal atrophy. Ibis prevalence may be higher than in the VIVA study, as women in the Will received a physical examination by a clinician, rather than reporting symptoms themselves. In a US-based survey of postmenopausal women aged 45-89 years, approximately 60% of past (n = 360) or never (n = 138) users of menopausal hormone therapy reported experiencing vaginal symptoms (such as dryness and pain associated with sexual intercourse), with over 90% of those finding them bothersome. ²¹

A longitudinal population-based studs of 438 Australian-born women, aged 45 55 sears, found th.it the percentage of women reporting vaginal dryness increased progressively as women approached and moved through the menopause - a five-fold increase in the prevalence of this symptom was noted, suggesting that vaginal dryness was a later consequence of the hormonal changes associated with the menopause. ²² Leiblum et al. ^{2 3} also investigated the prevalence of vaginal dryness. This survey included 6725 women aged 18-65 years, from 11 countries, including Canada (n = 638) and found that women from different countries differed considerably in their experiences, concerns and reports of vaginal dryness sexual pain. Indeed, the results of a number of surveys^12,19-21 suggest that women’s approaches to the menopause and vaginal atrophy vary from country to country, as do the needs and expectations of menopausal women.

In the survey reported by Leiblum et al., Canada was one of the three countries in which the greatest percentage of women indicated that they ‘always’ or ‘usually’ experienced vaginal dryness (almost one-quarter of women aged 50-65 years). ²³ The same age group in Canada reported that they found vaginal dryness very bothersome, which suggests that, in Canada, this symptom is more burdensome for women aged 50-65 years. In agreement with our current findings, and those of the full VIVA survey, ¹⁹ most women over the age of 50 in the Leiblum et al. study attributed vaginal dryness to ageing or the menopause. ²³

The majority of women in Canada recognized the negative impact that vaginal atrophy would have on their lives. They indicated that not only would it negatively impact their sexual intimacy (72%), but also their ability to have a loving relationships (39%) and overall quality of life (30%). Significant proportions of women believed that vaginal atrophy could limit their comfort of doing what they wanted to do, when they wanted to do it, making them feel less sexual (63%). The Canadian findings are comparable with those from the full VIVA survey, ¹⁹ especially for the quality-of-life aspect. As most women may live more than one-third of their lives post menopause, ²⁴ quality of life is an important consideration; a survey of Asian women found that the majority of women believed that improving vaginal health might improve their quality of life and would have liked to discuss their symptoms if their doctors had initiated the discussion. ^{2 5}

Although HCPs play a key role in helping postmenopausal women understand the symptoms of vaginal atrophy and the treatment options available, almost 40% of the Canadian cohort said that they would hesitate or fail to raise the subject of vaginal atrophy with their doctor (and almost two-thirds indicated that their doctor had not raised the topic of postmenopausal vaginal health); indeed, over halt had used/would use websites and blogs. If a dialogue was opened with patients, HCPs could recommend suitable and reliable online sources of information.

These results suggest that vaginal atrophy may still be regarded as a taboo subject, even among mothers and their daughters, as women were more likely to speak to their HCP than friends or family about the condition (82% versus 49%). In the US-based REVEAL (Ri sealing Vaginal Effects At mid-Life) survey, conducted with 1006 postmenopausal women (aged 45-65 years) and 602 HCPs,₂₆ half of respondents agreed that they had refrained from talking about their sexual health and intimacy with others, and that it was still taboo in society to acknowledge symptoms of menopause such as vaginal dryness. Interestingly, many of the HCPs surveyed also agreed that there were sensitivities around discussing the sexual health and intimacy of postmenopausal women and 73% also agreed that society was ‘more accepting of discussing men’s physical sexual problems than women’s physical sexual problems’. ²⁶ This may explain why some HCPs are reluctant to initiate discussion of women’s urogenital symptoms. However, postmenopausal women should be questioned about the symptoms of urogenital ageing, as many will not spontaneously report these symptoms unless asked directly and, as such, will suffer in silence. ¹³ Therefore, it is important that HCPs raise this topic.^6,13 In addition, therapeutic options should be discussed, as many women may try self-treatment before seeing a doctor.

An interesting difference between postmenopausal women in Canada and those in the full VIVA survey is the choice of HCP, with 72% of the Canadian cohort indicating that they were more likely to talk to their primary care physician/doctor if they experienced symptoms of vaginal discomfort versus only 52% in the full VIVA sample; similarly, only 30% of women in Canada would talk to their gynaecologist versus 47% of women in the full VIVA survey. Similar findings were noted when women were asked from whom they would obtain information to understand symptoms and treatment options, whom they would go to see if they experienced symptoms and whom they consulted for treatment if they had experienced vaginal discomfort. ¹⁹

Most women in this Canadian cohort felt that there was a lack of available information on symptoms of vaginal atrophy and treatment options for this condition. Only 42% felt that there was enough information. While many women eventually discussed symptoms of vaginal atrophy with their doctors, considerable proportions delayed this, some by as much as three years or longer. Worryingly, more than one-third did not seek help from a HCP.

Women in Canada and in the full VIVA survey were more likely to use OTC products to cope with the symptoms of vaginal atrophy than they were to treat the underlying cause of the condition. ¹⁹ The majority who had experienced vaginal atrophy had used lubricating gels and creams to treat their symptoms. This may be because they were unaware of the long-term effects of estrogen loss on the female urogenital tissues; some women may have believed that their symptoms would simply go away over time. Indeed, Santoro and Komi ²¹ found that 26% of women who had never used menopausal hormone therapy assumed that their vaginal atrophy symptoms would naturally resolve over time.

While almost two-thirds were aware of hormone-related treatments for vaginal atrophy, many women maintained negative associations with such treatments and were hesitant to consider them. Women appear to have safety concerns about using systemic HR I even at ‘the lowest effective dose over the shortest possible time’ and for most, safety is as important, or is more important, than efficacy; ² only 32% of women in Canada said that they would consider taking systemic HRT oral tablets and or patches. In contrast, more postmenopausal women in the Canadian VIVA sample (43%) would consider LET. Of the different options for LET, vaginal creams and tablets were preferred. However, the majority of women in Canada were not aware of the available LET options. Overall, the results of the treatment section of the survey for the Canadian cohort of respondents were comparable with the full VIVA survey population, ¹⁹ and the fact that many symptomatic women were not aware of and/or were not receiving effective treatment is a cause for concern.

Sexual dysfunction stemming from vaginal atrophy can have a major impact on quality of life and women should be afforded the opportunity to discuss sexual problems - early recognition of postmenopausal women distressed by sexual dysfunction is a key step towards effective therapeutic management. ¹⁴ LET (via vaginal tablets, creams or rings) has proved highly effective in reversing vaginal atrophy, improving vaginal symptoms and reducing dyspareunia; ¹ it is well-tolerated and associated with low rates of systemic absorption. ¹⁶ Furthermore, this treatment approach may have beneficial effects on other dimensions of sexual function; ¹ when used for treating exclusively vaginal symptoms, LET is the preferred treatment choice.^11-l5

Overall, the findings from Canada and from the full VIVA survey, ^{1 9} as well as other surveys reviewed, suggest that education initiatives and a proactive approach by medical practitioners, encouraging better dialogue, are needed to help raise awareness of vaginal atrophy and its treatments. It is important that women understand that they do not need to learn to live with distressing symptoms arising from vaginal atrophy, and that help is available.

Conclusion

Concurring with the findings of the full VIVA survey, women in Canada have a low understanding of vaginal atrophy. This shortcoming, coupled with the taboo associated with matters of vaginal health, means th.it many women do not access effective therapy. It is recommended that medical practitioners proactively raise the topic of vaginal health, help patients to understand that vaginal atrophy is a chronic condition and discuss the most appropriate treatment options.