Impact of Vulvovaginal Atrophy on Quality of Life and Sexuality Process of Aging physical health sexual activity Sexual function and aging desire androgen levels Michael L. Krychman MD Executive Director of the Southern California Center for Sexual Health and Survivorship Medicine Associate Clinical Professor UCI Department of Gynecology Oncology NAMS Annual Meeting Dallas Texas 2013 Delayed orgasm Fear of sexual or anorgasmia relations Dyspareunia and vulvar/vaginal atrophy estrogen levels Sherwin BB et al. Psychosom Med. 1987;49:397-409. Sarrel PM et al. J Reprod Med. 1998;43:847-856. 2000 JL Alexander, http://www.afwh.org 2 Manifestation of Estrogen and/or Androgen Loss: Symptoms Over Time Lila Nachtigall, M.D. Discussing Urogenital Atrophy Oncology Volume 13, 1999 Range of Estrogen secretion levels (pg/ml) Short-term symptoms Long-term symptoms Onset insidious with significant individual variability Mood, sleep, and/or Hot flushes acute cognitive changes Urogenital symptoms Decreased sexual activity Decreased arousal Decreased libido Among 2000 postmenopausal women in any given year: 20 will develop heart disease 11 will develop bone loss 6 will develop breast cancer 3 will develop endometrial cancer But nearly 100% will develop urogenital atrophy. Proceedings of a conference held in Charlottesville Virginia, September 21-23, 1997. 40 45 50 55 60 65 70 75 Age (y). 3 4 Estrogen Decrease and Its Impact on Sexual Functioning Estrogen Has Effects on All Tissue Components of the Vulvovaginal Area Estrogen decrease impacts the integrity of the female reproductive tract tissues Dyspareunia Decreased vaginal lubrication Atrophic vaginitis Decreased blood flow to reproductive organs Diminished vasocongestion Blood flow to the vulva (as measured by Doppler ultrasound velocimetry) increased by 50% when estrogen was administered to postmenopausal women Sarrel PM. Obstet Gynnecol. 1990:75:4:26S-30S. Epithelia (skin, vaginal) Promotes epithelial maturation and proliferation Maturation index relates to estrogen levels Ratio of parabasal to intermediate to superficials cells Skin appendages Blood vessels Increases vascularity and blood flow Nerves Specialized glands Stimulates glandular secretions (eg, Bartholin s gland) Sarrel PM et al. Fertil Steril. 1997;68:1125-1127. 2000 JL Alexander, http://www.afwh.org 5 Utian WH. Front Hormone Res. 1975;3:74-93. 6
7 Perivaginal Blood Flow During Estrogen Replacement Therapy Vulvovaginal Changes Can Lead to Sexual Symptoms Milliwatts (mw) 250 240 230 220 210 200 190 208.4 236.6 244.7 225.8 Baseline 1 Month 3 Months 6 Months Increase in blood flow values in women estrogen-deprived at baseline, and then administered conjugated estrogens. Vaginal dryness Dyspareunia Reduced or absent pleasure from direct genital stimulation Urinary symptoms Urgency, frequency, and possibly incontinence Predisposition to vulvar, vaginal, and lower UTIs If atrophy severe Vaginal shortening and narrowing Possible introital stenosis Prevents penetration or causes significant pain and/or bleeding from attempted penetration Possibly frequent sexual arousal and activity promotes genital health Wilbur JE et al. Menopause. 1998;5:43-51. Semmens J et al. JAMA. 1982;248:445-448. Leiblum S et al. JAMA. 1983;249:2195-2198. 8 What is Urogenital Atrophy (UA)? Dyspareunia & Bladder Symptoms UA is a condition of associated tissue and organ deterioration/dryness UA is due to estrogen depletion and is associated with urinary and vaginal symptoms UA is chronic and progressive UA contributes to atrophic vaginitis (AV) and sexual dysfunction in women Coital pain causes: Tightened, defensive myalgic pelvic floor Pelvic Floor Hypertonus Reflex inhibition of periurethral vascular arousal Mechanical urethral trauma Keil K. Current Women s Health Reports.2002,2:305-311. O Connell HE et al. J.Urol. 1998;159:1892-1897. D Amati G et al. J.Urol. 2002;60:191-195. 9 Slide courtesy of A Graziottin, 2004. 10 Clinical Symptoms of Urogenital Atrophy Symptoms That May Accompany Urogenital Atrophy Urethral Weak urinary stream Recurrent UTI Urge incontinence Urgency Frequency Urethral caruncle (lesions) Urethral erythema Friable urothelium Urinary Frequency Urgency Incontinence Frequent UTI Dysuria Vaginal Dryness with dyspareunia Burning Occasional bleeding Recurrent vaginitis or bacterial vaginosis Itching Pain Vaginal pressure Malodorous discharge Endocrine Aspects of Female Sexual Dysfunctin Workgroup. Second International Consultation on Erectile and Sexual Dysfunctions; Paris, France; June 28-July 1, 2003. 11 UTI = urinary tract infection. Keil K. Current Women s Health Reports 2002,2:305-311. Bachmann GA et al. Am Fam Physician 2000;;1:3090-3096. 12
13 Pelvic Floor Hypoestrogenism VVA is strongly Associated with FSD among Sexually Active Postmenopausal Women Levine et al: Menopause 15;4: 661-666 Decreased connective tissue Decreased elastic tissue Increased fatty infiltration Cellular atrophy Nerve degeneration Reduced smooth muscle tone Menopause Epidemiology Study is cross sectional population based study of women 40-65 years of age. Arizona Sexual Experience Study used Cross-sectional, population-based study of 1,480 sexually active, postmenopausal women Prevalence of vulvovaginal atrophy (57%) & FSD( 55%) Women with FSD were 3.84 times more likely to have vuvlovaginal atrophy than women without FSD. Women with sexual dysfunction ~4X more likely to also have vulvovaginal atrophy Endocrine Aspects of Female Sexual Dysfunction Workgroup. Second International Consultation on Erectile and Sexual Dysfunctions; Paris, France; June 28-July 1, 2003. Conclusion: Reducing symptoms of one condition may also relieve symptoms of the other What Do Patient Surveys Tell Us about VVA and QOL. ReVeal Survey (2008) Pfizer ReVeal ( Revealing Vaginal Effects at Mid Life) Healthy Women NovoNordisk VIVA ( Vaginal Health Insight, Views and Attitudes) CLOSER ( Clarifying Vaginal Atrophy Impact on Sex and Relationships) Shionogi REVIVE (REal Women s VIews of Treatment Options for Menopausal Vulvar/Vaginal ChangEs) Consisted of a phone survey among a representative sample of 1,006 PMW and an online survey of 602 HCP who treat postmenopausal women While most PMW surveyed recognized the importance of their sexual health, about 50% agreed that they refrain from talking about their sexual health/ intimacy with others 1/4 PMW surveyed experience dyspareunia at least sometimes. Even though it is painful, approximately 3/4 of these women engage in sex at least once a month, and one out of three engage in painful sex at least once weekly Healthy Women (2011) 56% of the postmenopausal women surveyed indicated they have experienced vaginal dryness. Among those women who reported experiencing vaginal dryness, 82% reported that their vaginal dryness is bothersome, with 20% reporting that their vaginal dryness bothers them either a lot or a great deal. 17% of women reported that their vaginal dryness did not bother them at all Negative Impact On Sexual Health But even if women are not discussing them, vaginal symptoms are having a negative impact on their sexual health. 63% who reported experiencing painful intercourse indicated that they avoid intimate situations because of their symptoms 70% who reported experiencing painful intercourse indicated their condition puts at least some strain on their sexual relationship with their partner 64% who reported experiencing vaginal dryness or 62% painful intercourse said they have learned to live with vaginal dryness/painful intercourse and have come to accept it
The CLOSER (CLarifying Vaginal Atrophy's Impact On SEx and Relationships) Survey: Implications of Vaginal Discomfort in Postmenopausal Women and in Male Partners. Nappi RE, et al. JSM 2013: Sept 10 (9) 2232-2241 93% of the postmenopausal women surveyed who reported experiencing painful intercourse indicated they still engage in intercourse even though it is painful, 40% engaging in intercourse at least once a week. 73% said they engage in painful intercourse because of their partner 80% report that vaginal dryness impacted sexual frequency 70% are less sexual now as compared to before menopause Results: 28% percent of women did not tell their partners when they first encountered vaginal discomfort, Having sex less often (women: 58%, men: 61%), less satisfying sex (women: 49%, men: 28%), and putting off having sex (women: 35%, men: 14%) were the main effects of VA. Intimacy avoidance was attributed to painful sex (women: 55%, men: 61%) and women's reduced sexual desire (women: 46%, men: 43%). Conclusions: VA has an adverse emotional and physical impact on postmenopausal women and their partners. VVA and Impact VVA has a big impact on a woman s relationship with her significant other (Husbands sometimes force their wives to seek medical help) VVA is more about sexual intimacy than loss of youth Some women deal with VVA by doing everything they can to avoid intimacy (e.g. waking up early before husband, intentionally putting themselves in situations that are not sexually inducing) VVA takes away a woman s sense of sexual spontaneity VVA also affects women in partaking in physical activities, such as biking, walking and running VVA also impacts a woman s enjoyment of life and her temperament Enjoyment of sex Sexual spontaneity Ability to be intimate Relationship w/ partner Sleeping Temperament Enjoyment of life Seeking new relationship Traveling Athletic activities Everyday activities Social activities Ability to work Women without a partner are more impacted by VVA impacts a woman s Sex Life and non-sexual aspects of life 22 Therapy Benefits Is Local Really Local? Maintains lubrication through production and regulation of mucosal and glandular secretions Promotes organ and tissue integrity Mucosal and epithelial health Elasticity of connective tissues Smooth muscle function Blood flow and parenchymal perfusion ph control for flora-friendly environment Acidifies vaginal ph through uptake regulation of proton secretion via apical membrane of ectocervical epithelial cells Kendall et. al. cautions that vaginal estradiol is contraindicated in postmenopausal women on adjuvant aromatase inhibitors1. Labrie et. al. demonstrate that even small doses of vaginal preparations Vagifem 25 µg; Premarin Vaginal Cream result in significant systemic absorption through estrogen naive vaginas(2). Naessen et al showed that 7.5 µg/24h could improve the lipid profile and bone density without affecting the endometrium3-5. Bachmann GA et al. Am Fam Physician. 2000;61:3090-3096. Belchetz PE. N Engl J Med. 1994;330:1062-1071. Keil K. Current Women s Health Reports. 2002,2:305-311. Gorodeski G et al. Endocrinology. 2005;146;816-824. 23 1Kendall A, et. al. Ann Oncol 2006;17:584-587. 2Labrie F, et. al. Menopause 2009;16:30-36. 3-5Naessen T, et. al. J Clin Endocrinol Metab 2001;86:2757-2762.; Am J Obstet Gynecol 1997;177:115-119.; Am J Obstet Gynecol 2002;186:944-947.
25 VVA: Medical Need That Is Not Fully Addressed Premenopausal women taking anti-estrogens or who have medical/surgical conditions that result in decreased estrogen levels are susceptible Cancer Chemo/radiation therapies Surgery/Hysterectomy/Oophorectomy Breast cancer patients 54% of patients on tamoxifen report sexual dysfunction Increased incontinence and vaginal dryness, decreased sexual activity Atrophic Vaginitis: Chronic and Progressive Early detection of signs and symptoms of vaginal atrophy is important VVA will likely worsen if left untreated Dyspareunia may lead to sexual dysfunction VVA impacts sexuality and QOL Treatment is considered efficacious and is well documented Mortimer JE et al. J Clin Oncol.. 1999;17:1488-1492. Ganz PA et al. J Natl Cancer Inst.. 2002;94:547-549. 26 ASK You cannot treat a problem if you do not know that one exists TELL Your health care professional cannot help you if he or she does not know there is a problem. 27