Symptoms,attitudes and treatment perceptions of vulvo-vaginal atrophy in UK postmenopausal women: Results from the REVIVE-EU study

Abstract

Objectives

To describe the attitudes and perceptions of postmenopausal women from the United Kingdom regarding menopause, vulvo-vaginal atrophy and its therapeutic management.

Study design

Post hoc analysis of the United Kingdom population from the REVIVE-EU Study.

Main outcome measures

The survey contained questions about women’s knowledge of menopause and vulvo-vaginal atrophy symptoms, impact on their life and sexual activities, communication with healthcare professionals and treatments.

Results

The most frequent symptom of menopause was hot flushes (75%). Vulvo-vaginal atrophy symptoms had a significant impact on participants’ ability to enjoy sexual intercourse (66%), spontaneity (62%) and ability to be intimate (61%); however, only 68% of women had been to their healthcare professional for advice. Half of the sample expected that doctors would initiate a discussion of menopausal symptoms and sexual health, but was in fact rare (5%). Only 27% were under current treatment without a clear therapy pattern, of which 43% used vaginal over-the-counter treatments, 28% prescription (Rx), and 13% both. Efficacy was the main limitation for over-the-counter treatments, while for Rx products were side effects and safety. Women highlighted the restoring of the natural condition of the vagina as the main goal for a treatment (35%). Many United Kingdom women did not feel the need to see any healthcare professional for their gynaecological symptoms. Overall satisfaction with treatment was only 44%.

Conclusions

Vulvo-vaginal atrophy remains underdiagnosed and undertreated in United Kingdom. There is a lack of coherent discussion about vulvo-vaginal atrophy symptoms with clinicians. Many United Kingdom healthcare professionals could improve proactive communication with patients about vulvo-vaginal atrophy.

Keywords

Postmenopausal women REVIVE survey sexual relationships vaginal dryness vulvar and vaginal atrophy

Introduction

Vulvo-vaginal atrophy (VVA) appears as a chronic and progressive condition in postmenopausal women caused by declining estrogen levels.¹ This has important physical consequences in the urogenital tracts (i.e. vaginal dryness, irritation, loss of elasticity, decrease of lubrication, dyspareunia),^1–6 and can impact considerably on a woman’s quality of life (QoL).^7–10

The European Vulvovaginal Epidemiological Survey (EVES) study, a recent cross-sectional survey of over 2000 postmenopausal Italian and Spanish women, revealed that over 90% presented for a gynaecological examination with at least one symptom of VVA.¹¹ Other recent reports have highlighted the continuing under-diagnosis and treatment of VVA by healthcare professionals (HCPs), and an unwillingness to raise or discuss symptoms by these women.^9,10,12–14

Many women appear to consider symptoms of VVA a natural aged-related process and may find the symptoms are not severe enough to raise with their HCP, and hope will resolve spontaneously. However, treatments are generally safe and effective and this delay in commencement at an early stage has significant implications on the long-term QoL for these women.^15–19

The current study belongs to a wider project, the REal women’s VIews of treatment options for menopausal Vaginal changEs-Europe (REVIVE-EU) survey,²⁰ and has as the main objective to obtain a broader understanding of VVA experienced by women from the United Kingdom (UK) after menopause. Two previous REVIVE studies evaluated the situation of postmenopausal women in Spain²¹ and Italy.²² The REVIVE project is based on an online survey asking about experiences and attitudes of postmenopausal women concerning vulvo-vaginal health and their sexual life, interactions with healthcare professionals (HCPs) and treatments. The definition of the current situation of postmenopausal UK women may help to define better management strategies at early stages in such populations, optimising resources and minimising the impact of VVA on daily life.

Methods

The methodology of the original REVIVE survey¹⁵ was used to conduct an online interview in four European countries (Italy, Germany, Spain and UK)²⁰ which included a final cohort of 3768 post-menopausal women (natural or surgically induced), aged 45–75 years, who reported at least one VVA symptom. In the UK, 8818 women were screened, and 1000 with VVA symptoms were selected to be demographically representative of the UK geographic regions.

The original REVIVE survey was translated and culturally adapted for its use in the four countries of the REVIVE-EU survey and was pre-tested in a subsample of 50 UK women (5%). The REVIVE-EU survey lasted around 35 min and its design was tested accounting for a margin error of 3.1% with a 95% confidence interval (CI).

The invitation to participate was sent to postmenopausal women with at least one VVA symptom after the onset of menopause (target population) by the panel (selected by age range). Participants completed the electronic survey between mid-June and mid-July of 2014. A three-step screening process was completed prior to the completion of the questionnaire (Figure 1). The interview contained questions about women’s knowledge of menopause and VVA symptoms, impact of VVA symptoms on their living and sexual activities, communication with HCPs, and treatment (current or previous use of over-the-counter (OTC) products, prescription (Rx) treatments for VVA and patient attitudes towards different available treatments). Rx treatments included vaginal medications containing estrogens with different dose ranges.

Figure 1.

Flow diagram of the study and presence of VVA symptoms in the UK participants.

Each corresponding accredited institutional ethics committee approved the comprehensive online questionnaire. The survey participants were informed of the study procedures and an informed consent to participate in the study was obtained in all cases. The study was conducted according to the World Medical Association Declaration of Helsinki. Eligible patients were those who fulfilled all selection criteria and who had valid data for the mentioned variables. The analysis was based on a descriptive statistics report summarised by relative frequency distributions for categorical variables.

Results

Population characteristics

Table 1 shows the main demographic and clinical characteristics of the UK population (n = 1000). Most of the UK cohort belonged to the 56–60 and the 61–65 years age range (27.1% and 24.4%, respectively). Among the population of surveyed women (Figure 1), 341 (44.4%) had experienced VVA symptoms during the last 30 days. At the time of the survey, 28% were receiving VVA therapy.

Table 1.

Baseline characteristics of the UK surveyed population reporting VVA symptoms (number of participants and percentages from a total sample of 1000 UK participants).

Age
45–50 years	51 (5.1)
51–55 years	199 (19.9)
56–60 years	271 (27.1)
61–65 years	244 (24.4)
66–70 years	175 (17.5)
71–75 years	60 (6.0)
Employment status
Employee	270 (27)
Self-employed	71 (7.1)
Out of work and looking for work	27 (2.7)
Out of work but not currently looking for work,	32 (3.2)
Homemaker	128 (12.8)
Retired	399 (39.9)
Unable to work	73 (7.3)
Marital status
Single	62 (6.2)
Married	621 (62.1)
Domestic partnership	92 (9.2)
Widowed	70 (7.0)
Divorced	132 (13.2)
Separated	23 (2.3)
Education status
No schooling completed	8 (0.8)
Elementary school	153 (15.3)
High school graduate, diploma or the equivalent	424 (42.4)
Trade/technical/vocational training	144 (14.4)
University degree	225 (22.5)
Master's degree	46 (4.6)
Children
None	223 (22.3)
1	165 (16.5)
2	377 (37.7)
3	155 (15.5)
≥4	80 (8.0)
Do you have any children living at home? Yes	224 (28.8)
Ever used treatment for VVA symptoms. Yes^a	511 (52.0)
OTC only	242 (24.2)
Rx only	142 (14.2)
Rx and OTC	68 (6.8)
Current use of treatment for VVA symptoms. Yes^a	276 (28.0)
OTC only	139 (19.9)
Rx only	91 (9.1)
Rx and OTC	17 (1.7)

^aEach participant can use more than one treatment.

OTC: over the counter; Rx: prescription; VVA: vulvo-vaginal atrophy.

Menopause awareness and VVA knowledge

In this selected cohort, the most common menopausal symptoms were: hot flushes (75%), night sweats (67%), insomnia or difficulties for sleeping (60%), weight gain (56%), decrease in sexual desire (52%), vaginal/vulvar dryness (48%), aching in muscles and joints (48%), frequent urination/incontinence (42%), feeling depressed/down (42%) and vaginal/vulvar irritation (41%). Only 15% of the cohort had been diagnosed with atrophic vaginitis/VVA. The familiarity with the condition of VVA, and the level of active search for information about VVA symptoms were 2.4 and 2.2 points, respectively (both in a scale from 1 to 7). Among the cohort of postmenopausal women who were aware of VVA, their knowledge and acquisition of information came through internet searches (41%) and discussion with family or friends (9%). The most accurate and acceptable term for VVA was vaginal dryness (33%).

Attitude and impact on daily activities and sexual life

After menopause, the reported symptoms associated with VVA were vaginal dryness (85%), pain during sexual intercourse (dyspareunia) (73%), vaginal tenderness (69%) and vaginal irritation (61%). Figure 2 presents the retrospective report of the onset of symptoms associated or linked with VVA in this cohort. Vaginal and vulvar irritation appears more frequently than other symptoms after two years of menopause. When asked to score symptoms compared to when they first appeared, vaginal/vulvar dryness was worse relative to when it first appeared (31%). Symptoms were also worse in the case of irritation (27%), tenderness (35%) and dyspareunia (38%). VVA symptoms were rated as bothersome in all cases, but dyspareunia was the most bothersome symptom acknowledged by participants (60%). Half of the sample (55%) felt VVA symptoms were uncomfortable, 47% felt symptoms were aging and 23% stated they felt less feminine.

Figure 2.

Initiation of the VVA symptoms noticed. Pre-menopause defined as before menopause; menopause defined as 1 year following last menstrual period.

Within the UK sample, during the previous year 18.3% of women had sexual activity at least once per week, 33.6% of them had sexual activity at least once per month, 22.6% a handful of times per year, while 25.5% did not have sexual activity. Seventy-one per cent had a partner of whom 85% lived together, and 48% could ask for advice or support from the partner about VVA treatment. Women with a partner reported having sexual intercourse at least once per month (49%) and 15% at least once per week. Women with a partner considered that getting satisfaction from sexual intercourse was important scoring a mean of 5.3 points (scale from 1 to 7). Women without a partner gave less importance in getting sexual satisfaction (mean of 3.8 points). Within this second group, the 12% had been without a partner for under 2 years and 32% had been without a partner for more than 10 years.

The most significant impact of VVA symptoms was on participants’ sexual enjoyment (66% somewhat or very interfering), followed by sexual spontaneity (62%), ability to be intimate (61%) and their relationship with their significant other (67%). Overall 43% of the sample considered VVA symptoms made them lose sexual intimacy, whereas 19% reported feeling less youthful. Women with and without a partner showed significant differences in terms of how strong their sexual desire was comparing before and after VVA symptoms occurred. On a scale from 0 to 10 (where 0 is no sexual drive and 10 is extremely strong), women with a partner considered sexual drive was strong (mean of 6.9 points) before VVA and had decreased at the time of the interview to a mean of 3.9 points (P < 0.005). A similar trend was observed in the group without a partner (6.0 vs. 2.4, P < 0.005).

HCP relationship

Over half of the sample (55%) went to their HCP for help within the previous 12 months (27% went once; and 28% had been twice or more), and the majority of these women asked their GP or practice nurse about their gynaecological needs (65%).

Almost half (45%) had never discussed their specific VVA symptoms with an HCP citing thoughts that symptoms were a natural part of aging (49%), not bothersome enough (24%) or simply too embarrassing (22%).

Fifty-six per cent of women expected their HCPs would talk about menopause symptoms. However, only 5% of women reported conversations were initiated by the HCP, whereas 31% of women initiated the conversation themselves during a consultation. Fifty-nine per cent of participants scheduled a visit to specifically discuss these symptoms.

Figure 3 shows how long (from <1 month to > 24 months) women experienced VVA symptoms before discussing them with an HCP. All symptoms were mainly present for a period of at least one to six months. The percentage of women satisfied with the information provided by the HCP about VVA symptoms and treatments (n = 446) was around 52%.

Figure 3.

Duration of VVA symptoms before discussing them with a healthcare professional.

Use and perceptions of VVA treatments

Concerning medication, 49% of the women surveyed have never undergone any treatment, with 27% currently using a treatment and the remaining 24% were lapsed on previous treatment. In total, 44% were found to have abandoned at least one treatment. The main reasons for abandoning treatments were messiness (24%), symptoms not bothersome enough (17%) and treatment unable to restore natural state of the vagina (16%). The main reasons for not taking any medication were that women did not consider symptoms bothersome enough (37%) and they assumed that symptom would resolve naturally (31%). Women reported their first treatment for VVA was initiated by a HCP in 25% of cases, whereas 22% started using OTCs after experiencing VVA symptoms before talking with a HCP.

Among women using treatments, 79% considered their dryness was quite or extremely bothersome (6/7 points, in a scale from 0 to 7), 49% reported that dryness was worse at the moment of the survey relative to when they first appeared, dyspareunia was quite or extremely bothersome in 64% of the sample, and it was considered worse now with respect to when it first appeared by 59% of the surveyed women. Among women who abandoned treatments, 34% considered dryness was quite or extremely bothersome, 43% reported the dryness was worse at the moment of the survey relative to when they first appeared, dyspareunia was quite or extremely bothersome in 50% of the sample, and it was considered worse now with respect to when it first appeared in 48% of the surveyed women.

In relation to the type of treatments, 43% of the UK sample used OTC treatments only, 28% Rx treatments only and 13% combined both Rx and OTC treatments. Table 2 summarises the overall perception of VVA treatment difficulties by the REVIVE-EU participants in UK. Women using OTC moisturisers considered the treatment was messy (37.7%), they were worried about the inability of the treatments to restore the natural state of the vagina (36.4%), and also had important concerns in relation to negative influence on sexual spontaneity and that they were not enough to relieve VVA symptoms (23.4%). Subjects using OTC lubricants were also mostly worried about the messy condition of treatment (36%), and that the medication was unable to restore the vagina’s normal condition (32.5%). Lastly, the main worries of women taking prescription vaginal products for VVA symptoms were the messy aspect of treatment (31%), concerns about safety long-term use (29.8%) and about hormone exposure (20.2%) and their significant issues with the product’s ability to restore the natural state of the vagina (21.4%).

Table 2.

Views of therapies for VVA in participants currently using treatment in UK.

	OTC personal vaginal moisturiser (n = 77)	OTC vaginal lubricant(n = 114)	Rx vaginal product(n = 84)
Issues related to route of administration
Messy	37.7	36	31
Not discrete	0	4.4	2.4
Not an oral pill	3.9	2.6	2.4
Do not like touching body	0	1.8	3.6
Issues related to convenience
Interrupts my daily activities/life	0	0.9	0
Inconvenient to administer	14.3	7	19
Cannot be sexually spontaneous	23.4	16.7	8.3
Difficult dosing schedule	1.3	0.9	3.6
Ritual/procedure of administering treatment	11.7	4.4	9.5
Issues related to side effects/safety
Concern about breast cancer	0	0	16.7
Concern about hormone exposure	2.6	0.9	20.2
Concern about safety for long term use	3.9	16.7	29.8
Vaginal discharge	7.8	3.5	11.9
Concern about other unwanted side effects	2.6	2.6	13.1
Experienced side effects	0	0	1.2
Concern about partner absorbing estrogen	2.6	0	4.8
Issues related to efficacy
Vagina not restored to its natural state	36.4	32.5	21.4
Not enough or no relief of vaginal/vulvar symptoms	23.4	18.4	13.1
Medication takes a long time to start working	7.8	0.9	7.1
Other
It’s expensive	19.5	5.3	2.4
My partner feels the treatment has negative impact on intimacy	1.3	3.5	1.2

Note: Data are given as percentages.

When asked to describe desired outcomes following treatment, the UK cohort of women highlighted restoring of the vagina to a more natural state (35%), to feel like their old self again (33%) and to enjoy sex more (32%), as the most important. When asked for a preferred method of administration for treatment, 40% of woman preferred a non-estrogen oral pill, whereas 21% preferred a vaginally administered treatment. Finally, among women dissatisfied with their current treatment (n = 137), 69% felt comfortable asking their HCP to change treatment, 67% told their HCP that the treatment was not working, 58% suggested a treatment they had heard of and would like to try and 22% felt comfortable asking to see a different or specific GP.

Discussion

This post hoc analysis of the UK participants (1000 postmenopausal women) of the REVIVE-EU study highlights the lack of VVA awareness and the problems associated with ineffective therapeutic management in this population. The analysis of the REVIVE survey in different European countries²⁰ already revealed a lack of knowledge of the condition by postmenopausal women, who demonstrated problems asking for professional advice, despite the clear impact of VVA on their sexual intimacy and general QoL.

In other EU countries and the US, vaginal dryness was the most common VVA symptom (around 80% in most cases),^{8,15,16,20–22} which appeared only in 48% of the UK women surveyed. The onset of VVA symptoms consistently occurred in the first years after menopause, except for vaginal irritation, which peaked after the third year. All VVA symptoms were rated as quite bothersome, especially dyspareunia, which was associated with a significant impact on intimate relations.

UK women stated that VVA symptoms made them feel uncomfortable and associated them with aging, rating the loss of intimacy with their partner as a significant concern. This trend was also found for the other countries evaluated in the REVIVE survey.²⁰ Women also stated that VVA symptoms have the highest impact on their relationship with their significant other, on enjoyment of sexual intercourse, on sexual spontaneity and on the ability to be intimate. This led towards a reduction of about 50% in sexual drive as a result of VVA symptoms. This trend is different from that observed for US women, as European participants acknowledged a significantly higher impact of VVA symptoms on sexual intercourse (72% vs. 59%) and partner interaction (60% vs. 47%) than the US population.²³

Bearing in mind that 71% of UK women in the Revive-EU survey live with a partner, this clearly illustrates that the impact of VVA on women’s intimate relationships and sexual well-being is very significant. Despite evidence that postmenopausal women would like to stay sexually active, VVA symptoms have a very strong negative effect on women’s sexual relationships, a trend already observed in other southern European postmenopausal women.¹⁸ In this sense, the current data in UK postmenopausal women postulated the real need for education on VVA symptoms and/or terminology. Women are unaware that the symptoms are due to a recognised medical condition, as already observed in the US population.²⁴ It appears there is low familiarity with the term VVA even among women who say they have been diagnosed. Another negative aspect is that women do not actively search for information about VVA symptoms. The internet is by far the most commonly used source of health information (41%). This is different from US populations who preferred written material from HCPs to be updated about the VVA condition but the health care provision for women in the UK is delivered predominantly from primary care who may have limited understanding of VVA themselves.²⁵

UK women differ from other countries in consulting gynaecologists as the primary HCP professional for gynaecological needs (Spain 78%, Italy 91%, Germany 92%, UK 9%).^20–22 The UK female population ask advice primarily from the general practitioner (41%). About half of all women evaluated in the REVIVE-EU survey see their HCP once a year,²⁰ with the UK being the exception as gynaecological check-ups were not routinely performed in the UK. However, 32% of UK women do not see any HCP for their gynaecological needs; only 27% go once a year and 45% state that they do not go yearly. Women who see a gynaecologist are more likely to discuss VVA symptoms and more likely to initiate treatment. At least 20% more women in Italy, Spain and Germany have discussed VVA with their HCP than in the UK.^20–22 The women spoke to their HCP about VVA symptoms one to six months after symptoms first appeared, in spite of being directly related to sexual problems and a lack of spontaneity.¹⁰ In the UK, women scheduled a visit specifically to discuss these symptoms, while other European populations wait for a check-up visit,^21,22 but contrary to what was reported, UK women still expect HCPs to initiate discussions on menopausal symptoms and sexual health.

The UK women were only partially satisfied with the discussion with their HCP. As the European REVIVE survey has already indicated,²⁰ the discussion of symptoms with an HCP has a significant impact on the incidence of the diagnosis of VVA. Whilst UK women expect their HCP to initiate a discussion on menopausal symptoms, it appears that this very rarely happens. The findings in the UK also suggest that although women would like a more pro-active discussion with their HCP, they trust their HCP and are willing to work with them to find a satisfactory treatment. The disconnection between education and communication by HCPs and postmenopausal women is equally prevalent in the UK population, as has been reported for American populations.²⁵

The UK has the highest incidence of untreated women with 49%, while Italy and Spain have the lowest (21%).^21,22 The percentage of “lapsed” treatments is similar for the UK and other European countries as well as the percentage of women that have abandoned at least one treatment.²⁰ Overall satisfaction was shown by 44% of subjects who completed or were taking OTC and/or Rx medication at the time. We did not find any predominant treatment in the UK population and the incidence of the OTC/Rx combination was low. This fact highlights the need for better management of the disorder as there is no clear understanding of VVA symptoms in UK, either in terms of defined protocols or pathways of care or regulation of information and management by the HCP.

Women in the UK initiated treatment for their VVA symptoms via different routes. Most commonly, a HCP wrote a prescription for medication to be used before using an OTC product. However, there are also a significant percentage of women who started using an OTC medication before talking with a HCP. UK women are less likely to try treatments and are less likely to be satisfied with the treatments they are taking. However, UK women were more likely to believe that symptoms were not bothersome enough and that they would disappear with time. The relationship with the HCP appears as a key variable for access to treatments and additional treatments to choose from. In the UK, the tendency not to use drugs seems more related to the manner of access to and the relationship with the HCP than to a prior objection. Interestingly, women who have not received any drugs tend not to discuss the situation with a HCP. The role of the doctor needs to be more active in creating multifactorial awareness on how to deal with the effects of menopause (both short and long term and primary and secondary effects). The doctor or other relevant HCP should facilitate discussions about menopause and needs associated with sexuality in order to deal with the disorder in the early stages to try to minimise the impact of chronicity and embedded behaviours.

The expectations related to treatments were to restore the vagina to a more natural state by reversing some of the changes that have occurred, to enjoy sex more and to be free of pain. These data coincide with other populations.^20–22 In the current sample, a non-estrogen oral pill for the VVA treatment is seen favourably by 40% of women, while a preference for vaginally administered creams is found in 21% of the sample. In the UK, efficacy was perceived as the main limitation for OTC vaginal moisturiser and lubricant products, while for Rx vaginal products it was safety.

Our results have some limitations inherent to the electronic origin of the survey that could be influenced by a bias in subjective perception of symptoms and treatment effects. Overall, our results have demonstrated that UK women have different attitudes and perceptions about VVA symptoms compared with other European countries. In addition, despite VVA symptoms after menopause being a common circumstance affecting QoL and sexual life, this condition remains overwhelmingly unknown by women suffering VVA as well as undertreated in UK. The real promotion of a change in VVA perception in UK women should reconsider the role of the HCP. Curiously, other UK populations have reported high rates of satisfaction with doctors’ communication skills;²⁶ however, this does not correspond to the rates observed for the UK population in the REVIVE study, as a substantial percentage of UK women do not initiate contact with a HCP for their gynaecological needs. Education of the HCP (nurse and doctor) in addition to the female sufferer is pivotal in order to increase the level of knowledge of this condition that appears so disturbing to postmenopausal women with significant consequences for quality of life if an appropriate treatment is not initiated at an early stage.

Footnotes

Acknowledgements

Manuscript writing and editorial support was provided by Mònica Giménez, PhD, and Emili González-Pérez, PhD, of TFS, S.L., with financial support provided by Shionogi B.V.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Claudine Domoney has received honoraria for lecturing and acting in an advisory capacity for a number of pharmaceutical companies, including Astellas, Novo Nordisk and Shionogi.

Hannah Short has received honoraria from Shionogi for acting as a consultant, and educational grants from Mylan and Theramex.

Martire Particco is an employee of Shionogi B.V.

Nick Panay has received honoraria for lecturing and acting in an advisory capacity for a number of pharma companies, including Abbott, Bayer, Besins, Mithra, MSD, Mylan, Novo Nordisk, Pfizer, SeCur, Shionogi and Theramex.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Manuscript writing and editorial support was provided by Mònica Giménez, PhD, and Emili González-Pérez, PhD, of TFS, S.L., with financial support provided by Shionogi B.V.

Ethical approval

The comprehensive online questionnaire was approved by the corresponding accredited institutional review boards at the respective institutions (University of Pavia, Palacios Institute of Women`s Health, Imperial College London). All survey participants were appropriately informed of the nature of the study and gave informed consent to participate before completing the online questionnaire.

Contributorship

The original REVIVE survey study design, methodology, data collection and analysis were previously published by Nappi et al (Maturitas 91, 2016:81–90). All authors reviewed and critically revised the manuscript and approved the final version of the manuscript.

ORCID iD

Martire Particco

References

Mac Bride

Rhodes

Shuster

LT.

Vulvovaginal atrophy. Mayo Clin Proc 2010; 85: 87–94.

Lachowsky

Nappi

RE.

The effects of oestrogen on urogenital health. Maturitas 2009; 63: 149–151.

Bruce

Rymer

Symptoms of the menopause. Best Pract Res Clin Obst Gynaecol 2009; 23: 25–32.

Santoro

and Komi

Prevalence and impact of vaginal symptoms among postmenopausal women. J Sex Med 2009; 6: 2133–2142.

Nappi

and Lachowsky

Menopause and sexuality: prevalence of symptoms and impact on quality of life. Maturitas 2009; 63: 138–141.

Palacios

Managing urogenital atrophy. Maturitas 2009; 63: 315–318.

Castelo-Branco

Biglia

Nappi

, et al. Characteristics of post-menopausal women with genitourinary syndrome of menopause: implications for vulvovaginal atrophy diagnosis and treatment selection. Maturitas 2015; 81: 462–469.

Nappi

Palacios

Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric 2014; 17: 3–9.

DiBonaventura

Luo

Moffatt

, et al. The association between vulvovaginal atrophy symptoms and quality of life among postmenopausal women in the United States and Western Europe. J Womens Health 2015; 24: 713–722.

10.

Parish

Nappi

Krychman

, et al. Impact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy. Int J Womens Health 2013; 5: 437–447.

11.

Palacios

Nappi

Bruyniks

, et al. The European Vulvovaginal Epidemiological Survey (EVES): prevalence, symptoms and impact of vulvovaginal atrophy of menopause. Climacteric 2018; 21: 286–291.

12.

Kingsberg

Krychman

ML.

Resistance and barriers to local estrogen therapy in women with atrophic vaginitis. J Sex Med 2013; 10: 1567–1574.

13.

North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause 2007; 14: 355–369; quiz 370–371.

14.

Khanjani

Panay

Vaginal estrogen deficiency. Obstet Gynaecol 2019; 21: 37–42.

15.

Kingsberg

Wysocki

Magnus

, et al. Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women’s VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. J Sex Med 2013; 10: 1790–1799.

16.

Nappi

Kokot-Kierepa

Vaginal health: insights, views & attitudes (VIVA) – results from an international survey. Climacteric 2012; 15: 36–44.

17.

Nappi

and Nijland

EA.

Women’s perception of sexuality around the menopause: outcomes of a European telephone survey. Eur J Obstet Gynecol Reprod Biol 2008; 137: 10–16.

18.

Nappi

Mattsson

L-Å

Lachowsky

, et al. The CLOSER survey: impact of postmenopausal vaginal discomfort on relationships between women and their partners in Northern and Southern Europe. Maturitas 2013; 75: 373–379.

19.

Novo

Data reveal the negative emotional and physical impact that a silent symptom of menopause has on U.S. women and their partners. Press Release, 5 October 2012.

20.

Nappi

Palacios

Panay

, et al. Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey. Climacteric 2016; 19: 188–197.

21.

Palacios

Cancelo

Castelo Branco

, et al. Vulvar and vaginal atrophy as viewed by the Spanish REVIVE participants: symptoms, management and treatment perceptions. Climacteric 2017; 20: 55–61.

22.

Nappi

Particco

Biglia

, et al. Attitudes and perceptions towards vulvar and vaginal atrophy in Italian post-menopausal women: evidence from the European REVIVE survey. Maturitas 2016; 91: 74–80.

23.

Nappi

and Krychman

ML.

The American-European difference in vulvar and vaginal atrophy views: a lesson from the REVIVE Survey. Climacteric 2016; 19: 252–255.

24.

Krychman

Graham

Bernick

, et al. The women’s EMPOWER survey: women’s knowledge and awareness of treatment options for vulvar and vaginal atrophy remains inadequate. J Sex Med 2017; 14: 425–433.

25.

Kingsberg

Krychman

Graham

, et al. The women’s EMPOWER survey: identifying women’s perceptions on vulvar and vaginal atrophy and its treatment. J Sex Med 2017; 14: 413–424.

26.

Coulter

Jenkinson

European patients’ views on the responsiveness of health systems and healthcare providers. Eur J

Pub Health 2005; 15: 355–360.