8 July, 2013

Erekson and colleagues recently published in the journal Menopause on their development of a Vulvovaginal Symptoms Questionnaire (VSQ) to determine the symptoms, emotions, life impact, and sexual impact of vulvovaginal symptoms on postmenopausal women [1]. They performed a number of validation tests which confirmed the utility of the questionnaire. Postmenopausal vulvovaginal symptoms include dryness, burning, pruritus, and dyspareunia. Vulvovaginal symptoms are common and have been reported by 9.6–44.4% of postmenopausal women. The authors found the VSQ to be a reliable and internally consistent instrument for measuring vulvovaginal symptoms in postmenopausal women. The authors demonstrated a reasonable validity of the VSQ, particularly in the absence of a gold standard for measuring vulvovaginal symptoms.

Comment

Estrogen deficiency impacts on vaginal tissue by reducing blood flow, thinning of vaginal epithelium, loss of collagenous support, obliteration of vaginal fornices, flattening of vaginal rugae and vaginal narrowing and shortening. It follows that vaginal transudate is reduced and lubrication during intercourse is impaired. Symptoms of vaginal dryness, burning, pruritus, and dyspareunia are common among postmenopausal women, especially when the women are directly questioned. Structural changes in the vulva include pendulous labia majora due to loss of fat tissue as a result of estrogen deficiency.

Estrogen deficiency affects the urinary bladder and urethra with thinning of the urothelium, particularly that of the trigone. This is combined with reduced bladder capacity as a result of detrusor over-activity and increased post-void residual volume, leading to symptoms of frequency, urgency and nocturia. The increase in vaginal pH above 5 encourages enteric bacterial growth and hence the increased incidence of urinary tract infection. This topic is of critical clinical importance and of significant unnecessary health-care expenditure, since many would have had prolapse repairs or extensive urological investigations long before a simple local estrogen replacement is instigated. In the majority of instances, symptoms improve after 8 weeks of intensive local estriol therapy and subsequent long-term maintenance estrogen therapy. Indeed, it can be argued that no such procedures should be undertaken before ensuring that the vaginal tissues are well estrogenized.

The main barrier to understanding the impact of these symptoms on quality of life as well as the clinical presentation is the embarrassment of the patient and her reluctance to discuss vaginal symptoms with her doctor. There is not enough educational material available that specifically tackles postmenopausal vaginal atrophy and its wide prevalence. In addition, many doctors do not initiate direct questions into vaginal symptoms as they do not appreciate the relevance or feel uncomfortable on how to formulate the question and what answer they will provide, thus opening avenues for extended consultations. Further, the relevance of estrogen deficiency is not understood in the majority of instances.

To devise a questionnaire like the VSQ that postmenopausal women can complete before the consultation with the doctor may save time and encourage the patient to talk about her symptoms. The publication of Erekson and colleagues has contributed to the literature with a significant attempt to provide a well-validated questionnaire that addresses the impact of vulvovaginal symptoms. For the interested clinician, it provides a focus for further questioning and more thorough understanding of the patient's complaint and helps to promptly administer a significantly effective treatment. It could be utilized in follow-up visits to evaluate responses to treatment. The authors' plan to evaluate discriminatory scores that equate with clinical significance is awaited with interest.

Farook Al-Azzawi
Gynaecology Research Unit, University Hospitals of Leicester, Leicester, UK

References

1. Erekson EA, Yip SO, Wedderburn TS, et al. The Vulvovaginal Symptoms Questionnaire: a questionnaire for measuring vulvovaginal symptoms in postmenopausal women. Menopause 2013 Mar 11. Epub ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/23481118