Impact of vaginal atrophy
on quality of life and sexuality

Executive Director, the Southern California Center for Sexual Health and Survivorship Medicine, Newport Beach, Calif

DISCLOSURE
The author is a consultant to Pfizer, Boehringer Ingelheim, Johnson and Johnson, and Semprea Laboratories and is a speaker for Warner Chilcott and Boehringer Ingelheim.

Vaginal atrophy is a common medical condition that is linked to menopause.^1,2 This condition is associated with sexual dysfunction disorders—women with vaginal atrophy are nearly four times more likely to experience sexual function disorders compared with those women with normal vaginal tissue.³ Pain and other symptoms contribute to or perpetuate low sexual desire or interest; decrease or discontinuation of sexual activity contributes to a cycle of intimacy avoidance, further diminishing desire.¹

In addition to the impact on sexuality and intercourse, vaginal atrophy has been shown to affect urinary function and may even impact activities of daily living, including sitting and exercise. these broad-range effects have been reported to cause significant emotional distress and reduced quality of life in postmenopausal women.^3,4 Embarrassment, cultural or religious taboos, and perceptions that these symptoms are an unavoidable part of normal aging may hinder women from initiating discussions about symptoms with their health-care professionals.¹

Various forms of documented effective treatment do exist, ranging from nonhormonal, over-the-counter moisturizers and lubricants for mild symptoms to local, minimally absorbed estrogen therapy for persistent symptoms.^5-9 Systemic estrogen therapy, used appropriately and with awareness of associated benefits and risks, may also be an option for treatment of the spectrum of postmenopausal symptoms.⁹ Vaginal atrophy and intercourse-associated pain, or dyspareunia, are not life threatening or physically debilitating; however, they are life altering and can have a significant impact on sexual satisfaction and overall quality of life.^3,4

Here, I will review the effect of vaginal atrophy, as well as address means by which clinicians can enhance patient sexual function and quality of life by initiating conversations with patients, discussing symptoms potentially associated with vaginal atrophy, and initiating effective treatment.

CROSS-LINKED SYMPTOMS OF VAGINAL ATROPHY

In addition to the systemic and familiar symptoms of menopause, such as hot flashes, mood swings, or night sweats, menopause is often associated with vulvar and vaginal changes; awareness of the association of these vaginal symptoms with menopause is lower among women compared with awareness of the systemic symptoms.¹⁰ In this condition, there is loss of collagen, adipose tissue, and capacity for water retention in the vulva, resulting in thinning of the epithelial surface; loss of the protective covering of the clitoral glans, causing in an increased vulnerability to irritation; thinning of the vaginal mucosa; loss of vaginal rugal folds; altered vaginal maturation index; reduced normal lactobacilli flora; changes in pH; and decreased vaginal blood flow and secretions normally associated with sexual arousal.^1,2,11

As a result of these changes at the cellular level, three categories of vaginal signs and symptoms may occur:

• vulvar and vaginal changes

• urinary complications

• and pain or discomfort associated with intercourse, or dyspareunia.^12-14

Reported prevalence of symptoms related to vaginal atrophy in postmenopausal women include vaginal dryness (27% to 55%), vaginal irritation or itching (19%), loss of interest in sex in women with vaginal dryness (32%), dyspareunia (32% to 41%), and difficulty with vaginal lubrication (39%).^1,15,16 these symptoms are a common—and commonly overlooked—accompaniment of female aging.

Urogenital atrophy is also often associated with urinary symptoms such as increased frequency and urgency of urination, painful urination, and increased incidence of urinary tract infections. these also have direct implications for quality of life and sexuality. In response to urinary symptoms, many women remain at home or close to home, change the liquids they consume or the amount they consume, and rely on increased use of sanitary protection. Pain and embarrassment related to urinary symptoms may worsen sexual function,¹ and vaginal atrophy has also been associated with recurrent cystitis and pyelonephritis.¹⁷

These symptoms become more common as women age—estimates of the prevalence of vaginal dryness increase with age. The frequency of stress urinary incontinence increases with age, and it has been observed that sexual interest, desire, arousal, lubrication, and orgasm are negatively influenced by this condition, which is also correlated with vaginismus and dyspareunia.¹⁸ Stress urinary incontinence is not directly attributable to vaginal atrophy; however the prevalence of this condition increases with age and it may worsen vaginal atrophy symptoms.² Decreased levels of sexual desire also tend to manifest with increasing age—to 49 years of age, 10% of women have low level of desire, but prevalence is 22% for those 50 to 65 years old, and 47% for those 66 to 74 years.¹⁸

In addition to becoming more common with aging, symptoms of vaginal atrophy may become worse unless appropriate treatment is given, creating a vicious cycle of sexual dysfunction. For example, women with sexual dysfunction—including those with low levels of sexual interest, arousal disorder, lubrication disorder, or dyspareunia associated with vaginal atrophy—may in turn adopt a strategy of sexual avoidance.^1,4,19 Avoidance may impact sexual frequency and can negatively impact the relationship. In addition, vaginal blood flow and secretions associated with arousal that help to maintain a healthy cytological environment in the vagina may be reduced; therefore, this avoidance may contribute to worsening of the symptoms of vaginal atrophy.¹ This relationship is illustrated in FIGURE 1.

EFFECT OF VAGINAL ATROPHY ON SEXUAL INTEREST AND RESPONSE

Menopause-associated decline in the estrogen level has been associated with decreases in contractions underlying the orgasmic response.⁴ However, the direct effect of decreased estrogen levels on sexual interest and coital frequency has not been fully elucidated. Decreased levels of estrogen resulting from menopause have been associated with a decline in women’s sexual interest, orgasm capacity, and frequency of coitus.^20,21 A study by Dennerstein and colleagues found that the frequency of sexual activities and libido were decreased most in postmenopause, with dyspareunia playing an important role.²² Research has also shown that lower estradiol levels resulting from menopause are associated with higher incidence of vaginal dryness, pain, and dyspareunia compared with patients with higher estradiol levels (≥50 pg/mL).²³

Estrogen therapy has been shown to increase vaginal lubrication and decrease atrophic conditions associated with menopause.²³ In addition, some research findings indicate that estrogen treatment may enhance sexual desire and enjoyment, have direct effects on vaginal lubrication, and improve orgasmic response.^21,23 These findings are somewhat contradicted by other studies of female sexuality and sexual activity during phases of the menstrual cycle, including those studies that examined women while receiving oral contraceptives, all of which demonstrated an inhibitory effect on female sexual desire and response associated with elevated estrogen levels.^21,23,24

In addition to the direct effects of estrogen on sexual desire and response, vaginal atrophy often results indirectly in reduced sexual activity. Vulvovaginal changes and other symptoms of vaginal atrophy can lead to a degradation of the vaginal surface, making it vulnerable to trauma, ulcerations, tears, and bleeding, even on minor contact.²⁵ Pain and discomfort, especially during intercourse, coupled with the associated physiological changes may lead to sexual dysfunction, vaginal contraction, and rigidity.

BARRIERS TO EFFECTIVE DIAGNOSIS AND TREATMENT OF VAGINAL ATROPHY

Often, vaginal complaints are the primary reason for consultations with the gynecologist or women’s health-care professional. It is estimated that vaginal complaints account for as many as 10 million office visits each year. The number of complaints may be higher if all related issues such as pain and discomfort are included.²⁶

However, for many women, the sexual problems that originate with vaginal atrophy may be difficult or embarrassing to discuss. A recent population study found that only 22% of women had discussed sexual issues with a physician/health-care professional since the age of 50.²⁷ Persisting cultural taboos about sex, embarrassment over sexual problems, or even self-blame about negative sexual experiences or sexual dissatisfaction—even when related to pain—can lead women to refrain from discussing their symptoms with a health-care professional.¹

Some women fail to seek a solution because they may attribute their symptoms to the normal effects of aging. Not realizing that the symptoms are related to an estrogen deficiency and are effectively and easily treatable conditions, some women—especially those who are elderly—may opt to discontinue sexual intercourse altogether.¹³

The cessation of coitus can have direct impact on relationship intimacy and can result in decrements in relationships and reduced quality of life. Dyspareunia, sexual dysfunction, and discontinuation of sex may negatively affect a woman’s sexual self- schema and how she perceives herself as a sexual being and may alter her perception of her own attractiveness as she ages.¹ A woman’s sexual dysfunction may also impact her partner’s sexual performance.⁵

Although some women accept their symptoms and do not seek treatment, others initially may try over-the-counter or home remedies, thereby postponing seeking the advice of a health-care professional. It is estimated that only 25% of women with the symptoms of vaginal atrophy seek medical treatment.¹³ However, the actual prevalence of the condition is unknown, because only a portion of symptomatic women seek treatment.^10,13 This delay often leads to women seeing a health-care professional only after excoriation of the vulva or other severe symptomatology emerges, complicating treatment.⁵

Barriers may exist on the part of the health-care professional as well. Health-care professionals often feel uncomfortable discussing sexual topics with an older female patient.¹⁰ They may wait for the patient to initiate the conversation or focus the limited time available for a gynecologic visit on the patient’s stated concerns.

Clinicians may be reluctant to investigate and probe about concerns not mentioned by the patient, thereby “opening the floodgates” and potentially causing time-management issues. The REVEAL survey found that only 36% of health-care professionals “often” discussed with patients the potential issue of pain associated with intercourse.¹⁰ In older patients, management of multiple medical conditions may take precedent, or the gynecologist may be reluctant to incorporate additional medications into an already complex treatment regimen.¹⁰ Also, clinicians may be poorly educated or personally embarrassed about the sexual response and sexual dysfunction issues in the older female patient. Many health-care providers are poorly educated about sexual functioning and dysfunction and often feel ill-prepared to address treatment issues or concerns.

Despite these potential barriers, it is imperative for clinicians to understand that 1) vaginal atrophy is a common and distressing condition, and 2) simple and effective treatments exist that can provide significant relief for patients and lead to drastic improvements in their overall quality of life.

PATIENT BARRIERS TO OPTIMIZING SEXUAL HEALTH: A TEACHABLE MOMENT FOR CLINICIANS

Given these potential barriers to identification and effective treatment, how can ObGyns and others who work as women’s health professionals best help their postmenopausal patients who are suffering in silence?

It is important to acknowledge the high prevalence of postmenopausal sexual function difficulties, including vaginal atrophy, and to routinely incorporate investigative questions on the topic of sexual complaints into your patients’ discussions and examinations.²⁸ Education of patients is also critical; it is important to provide patients with both validation of their concerns and effective treatment options. For specific suggestions on overcoming barriers to optimizing postmenopausal sexual health, see “Discussing postmenopausal sexual health concerns”.

TREATMENT PARADIGM

As I’ve discussed, vaginal atrophy is a common cause of sexual function problems in postmenopausal women; providing appropriate therapy, including locally applied hormonal therapy, can reduce the effect of this condition. Effective treatment for vaginal atrophy begins with the initiation of a frank and open dialogue about symptoms and sexual function; it continues with a full assessment of potential factors that may impact sexual health. For best results, it is important for health-care professionals to take a comprehensive approach to evaluation and treatment of vaginal atrophy in postmenopausal women. This approach incorporates local estrogen treatment, non-hormonal products to address dryness and irritation (which may be helpful during coitus), and other measures to address overall patient health, such as incorporating exercise and improving diet.¹⁶

Nonhormonal treatments, including over-the-counter moisturizing products, such as Replens and K-Y products, play a role in addressing vaginal symptoms. These products may help rehydrate the tissues on an ongoing basis. Lubricants may be used during coitus for further comfort. Constructive psychological and physical lifestyle change—such as eating a balanced healthy diet, increasing physical exercise, decreasing alcohol and tobacco use—may also positively impact sexual health by enhancing well-being, self-worth, and body image and increasing overall stamina. Increasing sexual activity can also play an important role in improving vaginal function.^4,16

Locally applied, minimally absorbed hormone therapy has been shown to be effective in slowing the vaginal remodeling associated with decreased estrogen levels. It is restorative in nature; however, data concerning effects on sexual desire and sexual frequency are more mixed.^21,24 Hormone therapy is not recommended for treatment of diminished libido in isolation.⁹ Treatment of moderate-to-severe vaginal atrophy with local hormone therapy can be effective in relieving dyspareunia, a common cause of intercourse avoidance.⁹ These therapies, in cream, tablet, or ring form, have also been shown to provide significant relief from distressing symptoms related to vaginal atrophy.^1,13,31 Conjugated equine estrogen cream is FDA approved for the treatment of moderate-to-severe dyspareunia. Locally applied, minimally absorbed estrogen may improve coital satisfaction by enhancing lubrication and increasing blood flow and sensation in vaginal tissues.⁹ Previous articles in this supplement have provided additional information on diagnosis and treatment of vaginal atrophy.

SUMMARY

Vaginal atrophy is a commonly overlooked problem, with significant negative impact on both sexual function and patient quality of life. Symptoms are progressive without treatment and contribute to a harmful cycle of intercourse-associated discomfort and sexual avoidance, which, in turn, contributes to worsening vaginal atrophy. These symptoms go beyond sexual function, potentially impacting activities of daily living, including sitting and exercise. Avoidance or pain during sex may impact a patient’s relationship with her partner and result in diminished self-esteem and relational intimacy. Urinary symptoms may be associated with discomfort and patient isolation.

Despite this broad impact, the patient suffers in silence, normalizing symptoms as “just part of getting older,” or being too embarrassed to raise the issue with her health-care professional. A broad range of effective treatment options is available for vaginal atrophy, with significant potential to mitigate the impact of this condition on sexual function and quality of life.

By incorporating sexual health concerns into the patient evaluation and discussion, diagnosing vaginal atrophy, and providing effective treatment, including nonhormonal and hormonal treatments, health-care professionals can improve the sexual function and quality of life of their postmenopausal patients.

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