Urogenital Atrophy – a silent epidemic 1
Paula Briggs1,2, Gayathri
Delanerolle3, Rachel Burton2, Jian
Qing Shi4,5, Haitham Hamoda6,
Dharani K. Hapangama1,2
Affiliations:
1Liverpool Women’s Hospital NHS Foundation Trust,
Liverpool, UK
2Department of Women’s & Children’s Health, Institute
of Life Course and Medical Sciences, University of Liverpool, UK
3University of Oxford, UK
4The Alan Turing Institute, UK
5Southern University of Science and Technology, China
6King’s College Hospital, London UK, Chairman of the
British Menopause Society
Corresponding author: Paula Briggs, Email: paula.briggs@lwh.nhs.uk
Urogenital atrophy describes the multiple changes in urogenital tissues,
most commonly due to hypoestrogenism associated with the menopause and
ageing. It results in an alteration of the appearance and function of
the vulva, vagina, urethra and bladder. The mucosal epithelium becomes
thinner and is prone to inflammation and trauma and the collagen fibres
in the dermal layer hyalinise and fuse, which in association with
fragmentation of elastin fibres, reduces tissue elasticity. These
changes can collectively result in pain and bleeding, most notably in
association with sexual activity. Most menopausal women are affected by
these changes in tissue quality to some degree, and therefore there is a
need for better communication and education for women, their partners
and their health care providers, to reduce any potential negative effect
on sexual function and quality of life2,3. Similarly,
to optimise clinical outcomes and maximise patient benefit, fit for
purpose diagnostic standards should be developed4.
There are two key research surveys that demonstrate valuable information
that could aid in advancing current clinical practices, namely The
European REVIVE Survey5 and
VIVA-LATAM6. The REVIVE survey was conducted in four
European countries including Germany, Spain, Italy and the UK (3768
postmenopausal women between the ages of 45-75 participated), while the
VIVA-LATAM survey was conducted in Latin American countries including
Argentina, Brazil, Chile, Colombia and Mexico (2509 women aged 55-65
participated). Both surveys were designed to establish awareness of the
effect of lack of estrogen on urogenital tissue quality. Symptoms were
frequent and treatment, particularly local hormone therapy was more
likely in women who have had a discussion with a health care
professional (HCP). Women wanted advice, but it was offered proactively
only in a small proportion of cases. The conclusion of both surveys
confirms that urogenital atrophy is an under-recognised, under-diagnosed
and under-treated chronic condition and they highlight that there is a
need for a public awareness and education campaign. Women surveyed in
REVIVE felt most concerned about loss of sexual intimacy and youth. This
was echoed by the findings in another survey CLOSER7,
a quantitative internet survey, including 8200 individuals from nine
different countries, with participation of 500 men and 500 women from
the UK. The results of this study highlighted the adverse emotional and
physical impact of urogenital atrophy on postmenopausal women and their
partners, with vaginal dryness and dyspareunia associated with loss of
arousal and desire. The conclusion focussed on the potential benefit of
more open communication with affected women, to improve access to
treatment and for healthcare providers to initiate the discussion.
Another study, the AGATA8 study, involved 913 Italian
women and following clinical assessment in women with symptoms,
prevalence of urogenital atrophy was estimated to range between 65-84%.
Authors concluded that urogenital atrophy is a common condition, which
is underdiagnosed and therefore undertreated. However, a follow up study
by the same group, undertaken in a subset of already diagnosed women,
demonstrated lack of consistency in the management of the condition from
a clinician perspective and lack of compliance from a patient’s
perspective9. This further reinforces the need for
education of both the clinicians and women and the requirement of
support including a validated objective method of assessment to assist
in diagnosis.
The impact of urogenital atrophy on sexual function is determined by a
number of factors including a reduction in blood flow to the vulva &
vagina with a decrease in vaginal secretions and an adverse effect on
neuronal function both of which can alter sensation and sexual pleasure.
Some authors have reported nerve density and size to be influenced by
dehydroepiandrosterone (DHEA) and androgens, thus explaining the
beneficial effects demonstrated with such therapy on postmenopausal
sexual function. Sexual intimacy remains an important aspect of
relationships for older women and enquiry about symptoms of urogenital
atrophy should be routinely included in all consultations about
menopause. This would help to remove a major barrier restricting access
to treatment for affected women, who find the subject difficult to
broach. Other hurdles to accessing treatment include limited research,
the cost of treatment and patient fear of treatment
options10.
Reported prevalence rates for urogenital atrophy vary even more widely
than the figure quoted for the AGATA study, with 10% -
84%7 of women going through menopause affected by
urogenital atrophy associated symptoms to some degree. Many women accept
symptoms as a normal part of aging and thus, may not seek medical
help20. It is difficult to predict which women will
develop urogenital atrophy, with some women unaffected possibly due to
genetically determined tissue quality and also possibly due to
production of DHEA from the adrenal glands. However, in general the
number of women affected increases year on year from menopause onwards
due to the progressive effect of estrogen deficiency.
The Stages of Reproductive Ageing Workshop (STRAW)11suggested that symptoms of urogenital atrophy are likely to present
between three and six years after last menstruation, although this can
occur at an earlier time. Some affected women may not associate their
symptoms with the menopause, if there is a long period between the
cessation of menstruation and the appearance of symptoms. For this
reason, it is particularly important that clinicians providing health
care to menopausal women proactively ask about common symptoms of
urogenital atrophy including vaginal dryness, itching, burning, pain
during sexual intercourse and urinary problems.