Resources

  1. Mitchell, C., Reed, S., Diem, S. et al (2018) Efficacy of Vaginal Estradiol or Vaginal Moisturizer vs Placebo for Treating Postmenopausal Vulvovaginal Symptoms: A Randomized Clinical Trial, JAMA Intern Med, 178 (5): 681-690. https://www.ncbi.nlm.nih.gov/pubmed/29554173
  2. Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. https://www.menopause.org/docs/default-source/2013/vva-position-statement.pdf

Transcript

Dr. Frank Domino:

Sharon, is a 61-year-old female, here for her annual exam. On her review of systems, she says she's miserable, especially when you discuss some of her GYN complaints. You stop and ask her to explain and she talks about pain with sexual activity, as well as constant discomfort. Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School, and joining me today is Jill Terrien, Associate Professor and Director of Nurse Practitioner Programs at the University of Massachusetts Medical School's Graduate School of Nursing. Hi Jill.

Jill Terrien:

Hi, Frank.

Dr. Domino:

So I feel bad for Sharon. She's like many women in my practice, but I guess I don't really know too much about how common vaginal symptoms are postmenopausally. Can you talk a little bit about who gets these symptoms and how frequently they occur?

Jill Terrien:

Sure. They're pretty common. So if you look at an age range of women between the ages of 40 and 75, depending on when they go through menopause, whether it's pre-menopause or whatever, about 50% of this population has vaginal complaints that could include dryness, itchiness, pain with intercourse, and really just a daily occurrence of not feeling well; a decreased quality of life.

Dr. Domino:

Yeah, it certainly sounds like it. When you think about 50% of women, that's every other women in our practice in the post-menopausal range. Well, it seems that there's more than a large number of products available at your local pharmacy to address post-menopausal vaginal symptoms. What do we know about them? What are the options, and how should we think about them?

Jill Terrien:

There are a lot of options, and they range from prescriptive to non-prescriptive, right? First there's hormone replacement therapy, which is... Really you gotta weigh risks and benefits, whether it's topical or oral, 'cause there's a vast array of lubricants and over-the-counter products that have many ingredients to very few ingredients that treat vaginal symptoms, vaginal dryness in particular.

Dr. Domino:

Okay. So you brought up a really good point about the oral hormone replacements and some of the risks and benefits. Tell me a little bit about what we know about best management of patients. What are our topical options and which ones work best?

Jill Terrien:

Okay. There was a recent trial that just came out that looked at three different products. One was low-dose estrogen. One was a vaginal moisturizer and the other was placebo, and they did it in about 300 women over 12 weeks, and these were women that had moderate to severe post-menopausal vaginal symptoms, and they measured this on the most bothersome symptom scale. They did a lot of other measurements, as well. But what they did is they had a great completion rate, and what they found is, that no matter what they used, they all had a decrease in their symptoms, particularly vaginal dryness, vaginal irritation and pain with intercourse.

Dr. Domino:

So the estrogen was no better than the placebo or the moisturizer?

Jill Terrien:

Correct.

Dr. Domino:

Wow! I didn't expect that.

Jill Terrien:

I know. It's a really interesting area. There is a lot of data that's recently come out, and actually if you go to the website, you will see that it'll have a paper on there that talks about the myriad of products that have many ingredients all the way down to a water-based product that you have as options for your patients.

Dr. Domino:

Okay. So this paper really helps us decide that we don't necessarily have to use something that's hormonally active. What are we gonna tell Sharon today? How do you pick a place to start and how do you follow up with this?

Jill Terrien:

Well, first of all, I wanna thank Sharon for being so candid about her pain and about her problems with her vaginal dryness and itchiness, because it's really a quality of life problem. And what I wanna say is, how long has been going on? Have you tried anything before? If you tried it, did it work, did it help? And get into a discussion about what the options are for it.

Dr. Domino:

How about you personally? What would you recommend first for Sharon?

Jill Terrien:

I think if she hasn't tried anything I'd just try an over-the-counter lubricant and see if that helps at all. One of the study drugs was something that you could use for two weeks, and then three times a week. It has a bio-film. And it's really gonna be what's gonna help the patient most. So I'd start with the least and work my way up from there to see what's gonna give her relief?

Dr. Domino:

Well, I think this is really remarkable Jill. I think we've long since gone to hormones, either orally or topically first, and then looked for alternatives. This is a practice changer and I think you're absolutely right. We should go with whatever is probably the least number of ingredients, and see how she tolerates it, and then go ahead from there. Would you recommend she only use it before sexual activity? Or would you recommend she used something every day?

Jill Terrien:

I think she's gonna have to figure out what relieves her symptoms the most, 'cause the other thing that goes along with this is the messiness factor. These gels and these lubricants, they can be messy. So maybe putting them in at night, showering before you go to work in the morning, if that's your schedule. And does that give her relief? Does she need to use it every day? Or is three days a week gonna work? And so it's making that dance with your patients to see how's it working for you? And that you're gonna have to have some trial and error with it. And I think probably the biggest thing is, is that as providers, we have to be proactive and sensitive to this. It's asking the question. People don't always check off the box. And so, it's talking about sexual health. I don't think we talk about it enough, and it's a really big quality of life factor.

Dr. Domino:

Especially when you're telling us that 50% of women in the post-menopausal age group suffer some of these symptoms. Well Jill, thanks so much.

Jill Terrien:

Thank you, Frank.

Dr. Domino:

Practice pointer: Vulvae vaginal symptoms are common in post-menopausal women. Ask about sexual health and symptoms that could alter the patient's quality of life.