Iu.Davydova, S.Kornienko, A.Limanskaya, V.Baranova

SI “Institute of Pediatrics, Obstetrics and Gynecology National Academy of Medical Sciences of Ukraine”, Kyiv, Ukraine

Introduction

Postmenopausal vulvovaginal health has the significant impact on quality of life of women in this age cohort, including interpersonal relationships, sexual function and working capacity. The problem is that many women do not appeal for a consultation by a doctor for advice on this, but try to cope with pathological symptoms on their own [8,9,10]. So, in spite of approximately half of postmenopausal women experience dryness, irritation, itching, dysuria, and dyspareunia, they are uninformed about natural hypoestrogenic postmenopausal vulvovaginal changes and the necessity to obtain safe, effective, and well-tolerated treatments. Because women hesitate to seek help for symptoms, a proactive approach to conversations about vulvovaginal discomfort would improve diagnosis and treatment [3,4,6].

It should be noted that even fewer menopausal women are aware of the individual risks of thromboembolic complications, which can significantly limit the likelihood of using hormone replacement therapy. Today, there are several options for medical care for women with atrophic changes in the vaginal mucosa and symptoms of dryness, including lubricants, ointments, vaginal forms of estrogen-containing drugs [2,5,7]. What is really needed is an individual selection of treatment for each woman with vulvovaginal atrophic changes, including psychologist’s help, an assessment of the risk of thromboembolic complications, the prescription of a drug with an optimal performance profile. Analyzing the data about usage of personal lubricants and moisturizers we can conclude that they are effective in reduction of discomfort and pain during intercourse for postmenopausal women with mild and moderate vaginal dryness, with real contraindications to estrogen. Regarding the choice of moisturizers women should be advised to choose a product with balance in both osmolality and pH, and naturally the most similar to vaginal discharge [2,5,6,8].

The aim is to evaluate the quality of health in women with vulvovaginal atrophy (VVA) and risks of thromboembolic disorders.

Materials and methods

There were 188 postmenopausal women (52-58 years of age) in the observation group, among them 38,3 % were diagnosed with mild arterial hypertension and 23,9% – with diabetes type 2. The criteria for inclusion in the observation group are the presence of symptoms of atrophic vulvovaginitis, an increased risk of thromboembolic complications (heterozygous or homozygous carriage of congenital thrombophilia genes, the presence of previous history of VTE, the presence of first-line relatives who died from thromboembolic complications up to age 50). The understanding of personal high risk of thromboembolic disorders led to the refusal to use any form of estrogen containing medicines (both oral or transdermal).The degree of VVA was evaluated by vaginal health index (Table 1) [1]. We used the complex approach for treatment: consultation with a medical psychologist, consultation of obstetrician – gynecologist about the physiology of postmenopausal changes in sex hormones metabolism and women with mild to moderate vaginal dryness were advised to use Gynorm (based on hyaluronic acid) for 14 days, once a day.

Table 1

Vaginal health index

Score

Overall elasticity

Fluid secretion characteristics

Vaginal pH range

Epithelial mucosa

Moisture

1

None

None

>6,1

Petechiae noted before contact

None, mucosa inflamed

2

Poor

Scant thin yellow

5,6-6,0

Bleeds with light contact

None, mucosa not inflaimed

3

Fair

Superficial, thin white

5,1-5,5

Bleeds with scarping

Minimal

4

Good

Moderate, thin white

4,7-5,0

Not friable, thin mucosa

Moderate

5

Excellent

Normal (white flocculent)

<4,6

Not friable, normal  mucosa

Normal

Results

 The data about the symptoms in women with VVA are represented in Table 2.

Table 2

Symptoms in women with VVA

Symptom

%

Vaginal dryness

82,9

Soreness

45,2

Itching

23,4

Burning

22,3

Pain during sexual contact

46,8

The data about сhanges in quality of life are presented in Table 3.

Table 3

Quality of life in women of the observation group before treatment

Parameter

%

Withdrawal of intercourse

23,9

Reduction of working capacity

51,1

Mood disorders

89,4

Reduction of daily activities

83,5

All the women in the observation group reported about the compliance with the treatment by Gynorm. It should be noted that 12 (6,4%) women had a slight burning sensation when using the gel for the first two days after start of the treatment, but none stopped the course. Also it is worth mentioning that 18 (9,6%)women noted the discomfort from leaking the gel to panties, but after repeated explanation the correct placement of the container in the vagina and changing the style of the introduction of the gel, these complaints were passed.

The data about the symptoms of VVA relief are represented in Table 4.

Table 4

Symptoms of VVA reported after the treatment

Symptom

%

Vaginal dryness

28,7

Soreness

7,9

Itching

11,7

Burning

4,7

Pain during sexual contact

9,5

The data about the changes in quality of life are presented in Table 5.

Table 5

Quality of life in women of the observation group after treatment

Parameter

%

Withdrawal of intercourse

1,1

Reduction of working capacity

7,4

Mood disorders

4,7

Reduction of daily activities

5,8

Data about VHI before and after treatment are represented in Table 6. In a group of women whose menopause period was less than 4 years, slightly better results were obtained than in the group of women with a menopause period of more than 4 years. It could be explained as VVA is a chronic, age-dependent condition caused by postmenopausal estrogen deficiency.

Table 6

Evaluation of VHI before and after treatment

Years of menopause

VHI before treatment

VHI after treatment

p value

Less than 4 years

11,2+3,1

21,6+2,4

<0.05

More than 4 years

10,2+2,1

19,8+2,5

<0.05

Conclusions

Many treatment options for postmenopausal women are now available, but we are sure, that therapy should be individualized, taking in consideration the woman’s preference and cardiovascular risks. In our observation group of postmenopausal women with VVA and high risk for thromboembolic disorders the significant improvement of quality of life was achieved. The high risk of thromboembolic disorders made it quite impossible to use estrogen- containing medications to correct symptoms of VVA and to improve the quality of life in this group of women.

Our approach was to unite the efforts of obstetrician-gynecologists and psychologists in establishing communication with this group of women. We explained that the symptoms could worsen in the absence of appropriate treatment, leading to progressive sexual dysfunction and potentially severe urogynecological consequences.

It was medical and psychological support that allowed the women of the observation group to be convinced that everything that happens with them has a physiological explanation, in addition, there are medications in modern medicine that can significantly improve their state of health without increasing their personal risk of thromboembolic complications.

The use of Gynorm as the medicine based on hyaluronic acid allows to obtain the significant improvement of quality of life due to influence on the possibility of vaginal epithelium to keep the liquid, counteract the development of infection, which, as a result, leads to a reduction in tissue trauma.

We strongly advice to start the treatment as early as the first symptoms of VVA occur and to maintaine it over time, due to the chronicity of the conditions. We do believe that gynecologists and psychologists in a team can do much to improve VVA by giving appropriate time and attention to this condition, thereby restoring sexual health and QoL of many menopausal women especially with high thromboembolic risks.

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