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Objective: The aim of this study is to assess the efficacy of microablative fractional CO2 laser therapy for genitourinary syndrome of menopause (GSM) management, when three, four, or five laser therapies were applied in a follow-up period of 12 months., Methods: Retrospective study evaluating GSM symptoms at baseline, and 1, 3, 6, and 12 months after last laser therapy. Visual analog scale, International Consultation on Incontinence Questionnaires- Female Urinary Tract Symptoms, International Consultation on Incontinence Questionnaires-Urinary Incontinence Short Form, Urogenital Distress Inventory-6, and Female Sexual Function Index were used for assessment of GSM symptoms' intensity or bothering and parameters of sexual function., Results: Overall, 94 women were included (35, 35, and 24 received three, four, and five therapies, respectively). All GSM symptoms improved statistically significantly. Intensity of dyspareunia and dryness decreased from 9 (5-10) (median [minimum-maximum]) and 8 (0-10) at baseline to 0 (0-6) and 0 (0-8), 1 month after last laser therapy (all P < 0.001), respectively. FSFI and frequency of sexual intercourse increased from 10.8 (2-26.9) and 1 (0-8) at baseline to 27.8 (15.2-35.4) and 4 (2-8) 1 month after last laser therapy (all P < 0.001), respectively. The positive laser effect remained unchanged throughout the 12 months of follow-up. The same pattern was followed for symptom-free rates. Four or five laser therapies may be superior in lowering the intensity of GSM symptoms in comparison to three laser therapies, in short and long-term follow-up. Differences between four and five laser therapies were not found., Conclusions: Laser therapy may provide significant improvement and/or absence of GSM symptoms up to 12 months follow-up, irrespectively to the number of laser therapies applied. Symptoms intensity 1 month after last laser therapy may be indicative of GSM symptoms intensity at 12 months. One month after third laser therapy is the critical time to decide whether treatment extension should be offered.

Objective: The aim of the study was to determine the utility of vaginal pH as a marker of menopause and vulvar and vaginal atrophy (VVA) before and after local estrogen treatment., Methods: Vaginal pH was determined using standard pH paper strips in two clinical trials involving postmenopausal women with signs and symptoms of VVA evaluated before and after intervention with vaginal estradiol in softgel capsules. The utility of vaginal pH was evaluated as a screening method for VVA due to menopause and correlations were analyzed between vaginal pH and VVA symptoms, physical changes, and maturation of the vaginal epithelium., Results: Changes in vaginal pH were significantly correlated with changes in superficial and parabasal cell counts; vaginal epithelial changes of color, integrity, thickness, and secretion; and the VVA symptoms of vaginal dryness and dyspareunia (vaginal pain with intercourse)., Conclusions: Vaginal pH consistently correlated with parabasal and superficial cells and the visual vaginal epithelial changes and symptoms of dryness and dyspareunia, and is thus a simple outpatient procedure that reflects the hormonal milieu and its effects on the vaginal epithelium.

Objective: To assess vulvovaginal symptoms and urinary incontinence in postmenopausal women. Secondarily to evaluate factors related to the severity of vulvovaginal symptoms and the internal consistency of the used tools., Methods: In this cross-sectional study, the Spanish language version of the 21-item Vulvovaginal Symptoms Questionnaire (VSQ) and the 3-item International Consultation on Incontinence Questionnaire (ICIQ-SF) were applied to 122 postmenopausal Spanish women aged 45 to 75 years., Results: Mean age of the whole sample was 59.5 ± 4.9 years; 89.3% had natural menopause, 77.9% reported vulvovaginal symptoms, 54.9% had urinary incontinence, 54.1% were sexually active, and 77.0% currently had a partner. Calculated Cronbach's alpha coefficients were 0.87 and 0.88 for the VSQ and the ICIQ-SF, respectively. Multiple linear regression analysis determined that total VSQ scores (more severe vulvovaginal symptoms) were positively correlated with female age, parity, surgical menopause, being sexually active, economic problems, phytoestrogen use, and more severe urinary incontinence. An inverse correlation was found with urban residency and time since menopause onset., Conclusions: Internal consistency of the VSQ and the ICIQ-SF was good in this postmenopausal sample in which age, sexual activity, urinary incontinence, drug use, and other personal aspects were important covariates determining the severity of vulvovaginal symptoms.

Objective: Previous studies demonstrated that a cognitive behavioral therapy (CBT) program delivered in group sessions is effective in alleviating treatment-induced menopausal symptoms in women with breast cancer, but also that in-person CBT is inconvenient for some women and can result in low levels of program compliance. A promising, alternative approach is to use the Internet to make this form of CBT more accessible and feasible for patients. The objective of this study was to evaluate the feasibility and to generate preliminary data on the efficacy of a guided, Internet-based CBT program., Methods: Twenty-one participants with treatment-induced menopausal symptoms started the guided Internet-based CBT program. Self-report questionnaires were completed at baseline and at 10 weeks (posttreatment). Counselors' evaluations were obtained via interviews. Primary outcomes were program usage, compliance rates, and participant and counselor satisfaction. Secondary outcomes were overall levels of endocrine symptoms and hot flush/night sweats problem rating., Results: Ninety percent of participants completed the program as planned. Satisfaction rates were high among participants and counselors. Small revisions to the program were advised. There was a significant decrease over time in overall levels of endocrine symptoms and hot flush/night sweats problem rating., Conclusions: These findings suggest that an Internet-based CBT program for women with treatment-induced menopausal symptoms is feasible and promising in terms of efficacy. The efficacy of the CBT program is currently being investigated in a larger randomized controlled trial.

Objectives: To assess safety and efficacy of a fractional CO2 laser therapy for the treatment of genitourinary syndrome of menopause (GSM) with follow-up to 1 year posttreatment., Methods: Women presenting with GSM and meeting inclusion criterion were enrolled. Visual Analog Scales were used to grade vaginal pain, burning, itching, dryness, dyspareunia, and dysuria. Dilators were used to rate vaginal elasticity at baseline and at each follow-up visit. Before each treatment and at follow-up, Vaginal Health Index scoring and Female Sexual Function Index questionnaires were completed. Women received three vaginal laser treatments spaced 6 weeks apart. Participant satisfaction was measured on 5-point Likert scales (1 = very dissatisfied, 5 = very satisfied)., Results: Of 30 women (mean age 58.6 ± 8.8 years), three were lost to follow-up at 3 months and six at 1 year. None were discontinued or withdrew due to an adverse event. Average improvement in Visual Analog Scale scores for all symptom categories was statistically significant at 3 months and remained so through 1 year, except dysuria. Differences between data at 3 months and 1 year were not statistically significant, indicating persistence of positive outcomes. Average overall improvement in pain was 1.9 (±3.4), burning 1.9 (±3.1), itching 1.4 (±1.9), dryness 5.9 (±2.8), dyspareunia 4.9 (±3.3), and dysuria 0.9 (±3.1). Improvement in average Vaginal Health Index and Female Sexual Function Index scores was also statistically significant (P < 0.0001). Of 19 women undergoing dilator examination at 1 year, 18 (94.8%) were comfortable with the same or larger dilator size. Twenty-two of 24 women (92%) were satisfied or extremely satisfied with the treatment at 1 year., Conclusions: Based on study data up to 1 year, the fractional CO2 laser may be an effective and safe treatment for women suffering from symptoms of GSM, although additional studies with larger populations and placebo control is needed to confirm these results.

Objective: The aim of this study was to evaluate the efficacy and acceptability of a second generation of vaginal laser treatment, the vaginal erbium laser, as a nonablative photothermal therapy for the management of genitourinary syndrome of menopause in postmenopausal breast cancer survivors., Methods: The study was performed using an erbium laser crystal yttrium-aluminum-garnet (XS Fotona Smooth, Fotona, Ljubljana, Slovenia) with a wavelength of 2,940 nm. Forty-three postmenopausal breast cancer survivors were treated with three laser applications every 30 days. Symptoms were assessed before the treatment and after 1, 3, 6, 12, and 18 months, using two methods, subjective Visual Analog Scale (VAS) and objective Vaginal Health Index Score (VHIS). The procedures were performed on an outpatient basis without anesthesia or drug use before or after the intervention., Results: From baseline values of 8.5 ± 1.0 cm, vaginal dryness VAS scores were 4.4 ± 1.2 cm after the third treatment and 5.5 ± 1.5 cm 12 months after the treatment (P < 0.01 vs basal values), whereas they were 7.5 ± 1.8 cm after 18 months from the last laser application (NS vs basal values). From baseline values of 7.5 ± 1.5 cm, dyspareunia VAS values decreased to 4.2 ± 0.9 cm after the third treatment and 5.1 ± 1.8 cm 12 months from the last laser application (P < 0.01 vs basal values), whereas they were 6.5 ± 1.8 cm after 18 months from the last laser application (NS vs basal values). VHIS, from baseline values of 8.1 ± 1.3, was 21.0 ± 1.4 after the third treatment and 18 ± 1.8 12 months from the last laser application (P < 0.01 vs basal values), whereas they were 14.8 ± 1.5 cm after 18 months from the last laser application (NS vs basal values). No adverse events were recorded during the study., Conclusions: This study suggests that the vaginal erbium laser is effective and safe for the treatment of genitourinary syndrome of menopause in breast cancer survivors.

Objective: The aim of the study was to evaluate the prevalence and association of subjective symptoms and objective signs of vaginal atrophy (VA)., Methods: A cross-sectional multicenter study was performed on 913 postmenopausal women consulting 22 gynecological outpatient services. The prevalence of subjective symptoms and objective signs of VA was stratified by years since menopause and related to each other., Results: In women a year after menopause the prevalence of vaginal dryness was 62% to 67%, of dyspareunia 67.5%, of itching 40%, of burning 48%, and of dysuria 15%. In women years after menopause the prevalence of vaginal dryness and dysuria was higher (85% and 30%, respectively) and that of itching and burning did not exceed 50% and 52%, respectively. The prevalence of dyspareunia was 75% in postmenopausal women after 6 years, but the rate decreased to about 41% years later. The prevalence of objective signs was also different. In women 1 year after menopause the prevalence of basic pH was 78%; of mucosal pallor, rugae thinning, and objective vaginal dryness about 60% to 62%; of mucosal fragility 35%; and of the presence of petechiae 15% to 20%. The prevalence of all objective signs was progressively higher with time since menopause reaching a value of 90% for pH > 5, mucosal pallor, and rugae thinning; of 80% for mucosal fragility; and of 51% for petechiae. There was no strict association between signs and symptoms, apart from subjective and objective vaginal dryness (k index = 0.820; sensitivity 0.96; specificity 0.82)., Conclusions: The results show that objective signs and subjective symptoms of VA have a different prevalence distribution in the years after menopause and are not strictly associated.

Objective: This study aims to evaluate the sexual function and quality of life (QoL) of naturally postmenopausal women affected by genitourinary syndrome of menopause who were treated with an ultralow-concentration estriol vaginal gel (0.005%)., Methods: Postmenopausal women with vulvovaginal atrophy symptoms and sexual disorders were enrolled in a case-control study. Women were treated with vaginal gel (containing 50 μg of estriol) daily for 3 weeks and then twice weekly up to 12 weeks. Determination of vaginal maturation index, evaluation of vaginal pH, and assessment of vaginal atrophy symptoms were carried out. QoL, sexual function, and distress were investigated using the Short Form 36, Female Sexual Function Index, and Female Sexual Distress Scale questionnaires. Changes between baseline and week 12 were assessed., Results: Sixty-eight women were included in the study group, and 42 women were included in the control group. Women on estriol vaginal gel had a significant increase in vaginal maturation index and improvement of vaginal pH compared with baseline (P < 0.05). Mean total Female Sexual Function Index score improved, and Female Sexual Distress Scale score decreased from baseline to follow-up. Results from the Short Form 36 questionnaire showed a significant improvement in the overall index of somatic aspects (P < 0.05). The control group showed no changes from baseline evaluation (P = NS)., Conclusions: Estriol vaginal gel (0.005%) therapy significantly improves the trophism of the vaginal mucosa and the sexual health and QoL of naturally postmenopausal women. These results confirm that low doses of vaginal estrogen must be considered as the first choice for the initial treatment of postmenopausal genitourinary symptoms.

Objective: This study aims to identify factors associated with greater impact of vaginal symptoms on the functioning and well-being of postmenopausal women., Methods: Postmenopausal women who reported vaginal dryness, itching, irritation, or pain with sexual activity completed the multidimensional Day-to-day Impact of Vaginal Aging (DIVA) questionnaire and underwent assessment of multiple sociodemographic and clinical factors that have the potential to influence the impact of vaginal symptoms. Multivariable linear regression analyses examined relationships between selected participant characteristics and DIVA scale scores assessing symptom impact on activities of daily living, emotional well-being, self-concept and body image, and sexual functioning., Results: Among 745 symptomatic participants, the mean (SD) age was 56 (9) years, and 66% were racial/ethnic minorities. Women with comorbid depression reported greater impact of vaginal symptoms on all dimensions of functioning and well-being measured by the DIVA questionnaire (11%-22% estimated increase in impact scores associated with every three-point increase in Hospital and Anxiety Depression Scale scores). Women with urinary incontinence also reported greater impact of vaginal symptoms on activities of daily living, emotional well-being, and self-concept and body image (27%-37% estimated increase in impact scores). Age, partner status, frequency of sexual activity, general health, and body mass index also predicted greater impact on at least one domain., Conclusions: Findings suggest that special efforts should be made to identify and treat vaginal symptoms in postmenopausal women known to have depression or urinary incontinence, as these women may experience greater impact of vaginal symptoms on multiple domains of functioning and quality of life.

Objective: This work aims to review a novel case of a retained 2-mg estradiol vaginal ring used to treat postmenopausal urogenital atrophy. The ring was found adhered to the posterior fornix by a fibrotic band. This is the first reported case in the medical literature., Methods: We describe the case of a postmenopausal woman experiencing symptoms of urogenital atrophy. Factors predisposing her to this complication (such as inconsistent use of other forms of vaginal estradiol, initial incorrect use of the ring with two rings in place, and subsequent vaginal stenosis and irritation requiring vaginal dilator therapy at one point in her treatment course) were analyzed. A review of the medical literature was performed to examine the safety profile of estradiol vaginal rings used to treat urogenital atrophy and to investigate the incidence of complications., Results: Two-milligram estradiol vaginal rings treat symptoms of urogenital atrophy by delivering a constant supply of estradiol to the vaginal epithelium. The ring has been shown to be as safe and effective as other forms of vaginal estrogen. Vaginal irritation is a known complication of 2-mg estradiol vaginal rings and other vaginal implants; however, none of the randomized controlled trials that have compared the ring to other vaginal estrogen forms have reported adherence of the ring to the vaginal epithelium., Conclusions: Providers should be aware of the possibility of ring adherence to the vaginal epithelium and should exercise caution in using the 2-mg estradiol vaginal ring in women with significant vaginal stenosis or irritation.

Objective: Previous studies on menopausal transition and sexual functioning have mixed findings. Most are cross-sectional, exclude hormone therapy users and hysterectomized women, and are unable to separate the effects of age from menopause or account for psychosocial, vasomotor, and somatic factors. We examine relationships between women's reports of a change in sex life and difficulties with intercourse and their experience of menopausal transition, use of hormone therapy, and hysterectomy., Design: A British cohort study with 1,525 women were followed since their birth in 1946 and annually from age 47 to 54 years. The outcome measures were self-reported change in sex life and difficulties with sexual intercourse over 8 consecutive years., Results: Compared with women who remained premenopausal, peri- and postmenopausal women reported a decline in sex life (mean difference [95% CI]: perimenopausal, -0.1 [-0.2 to -0.03]; became postmenopausal, -0.1 [-0.2 to -0.1]) and were more likely to report difficulties with intercourse (perimenopausal, 0.6 [0.1 to 1.1]; postmenopausal, 1.0 [0.5 to 1.5]) beyond the effects of aging and other psychosomatic factors. Women reported difficulties with intercourse more often if they had been on hormone therapy for more than a year (0.5 [0.03 to 1.0]) or if they had undergone a hysterectomy (0.6 [0.1 to 1.1]); no differences were found for change in sex life. For both outcomes, vaginal dryness was the major risk factor. Married women were also more likely to report adverse outcomes. Somatic symptoms and hot flushes/cold sweats were associated with difficulties with intercourse, whereas psychological symptoms, stressful lives, increasing age, and smoking were associated with a decline in sex life., Conclusions: Menopausal transition status had an independent effect on the reported change in sex life and difficulties with intercourse. The results support health professionals in their development of management strategies that (a) consider treatments directly for vaginal dryness, (b) identify somatic symptoms for difficulties with intercourse, (c) investigate psychological factors for a reported decline in sex life, and (d) for both outcomes, consider the potential role of intimate partners.

Objective: The purpose of this study was to describe the perimenopausal symptom experience of Filipino American midlife women with particular emphasis upon estrogen-related menopause symptoms (day sweats, hot flashes, night sweats, and vaginal dryness)., Design: A cross-sectional, descriptive survey was used to generate symptom experience data for 165 Filipina Americans between the ages of 35 and 56 who self-identified as Filipina American and were English-language proficient. The community-based sample completed questionnaires composed of sample characteristic questions and a 51-item menstrual symptom checklist with menopause-related symptoms embedded in it., Results: Sample characteristics and symptom experience were compared among age groups of 35 to 39 (n = 39), 40 to 44 (n = 40), 45 to 49 (n = 37), and 50 to 56 (n = 49) and by perimenopausal phase, defined as premenopausal (n = 85), transitional (n = 33), and menopausal/postmenopausal (n = 47). The most reported individual symptoms were "felt energetic" (86.1%) and "well-being" (83.6%). Estrogen-related menopause symptoms were reported as "vaginal dryness" (39.4%), "hot flashes" (37.6%), "day sweats" (27.9%), and "night sweats" (24.2%) by the total sample. Distress associated with estrogen-related menopause symptoms was reported by 17% (n = 28) of all women. Subjects' chi 2 tests indicated that 50-to-56-year-old women were more likely to report fatigue/sleep symptoms, physical symptoms, and estrogen-related menopause symptoms than all other age groups. When compared by perimenopausal phase, transitional women were more likely to report moderate or extreme severity for day sweats. Premenopausal women were more likely to report minimal or mild severity and women in the perimenopausal transition were more likely to report moderate or extreme severity on estrogen-related menopause symptoms., Conclusions: Filipino American midlife women appear to consider the perimenopausal transition in a positive light and experience little distress associated with estrogen-related menopause symptoms experienced. Findings from this study suggest that Filipina Americans view perimenopausal symptoms as part of a normal life stage that does not warrant concern.