PHILADELPHIA — For menopausal women with vulvovaginal atrophy, cost and worries about the risks associated with estrogen therapy are among the main barriers to treatment, according to results from a recent survey of obstetrician/gynecologists (ob/gyns) and primary care physicians.
But just as problematic is the hesitation on the part of some clinicians to ask women about problems such as painful intercourse, despite how severely dyspareunia can affect a woman’s quality of life, said Sheryl Kingsberg, PhD, from MacDonald Women’s Hospital, University Hospitals Cleveland Medical Center, who is president-elect of the North American Menopause Society (NAMS).
Of the 64 million postmenopausal women in the United States, at least half suffer from vulvovaginal atrophy, she reported here at the North American Menopause Society (NAMS) 2017 Annual Meeting. But only about 7% are taking prescription therapies.
Genitourinary syndrome of menopause, which includes vulvovaginal atrophy, is underdiagnosed and undertreated, Dr Kingsberg told Medscape Medical News.
“The most bothersome symptoms are going to be dyspareunia or dryness, which lead to pain with sexual activity,” she explained. “Not only do women not realize that this is related to menopause, they don’t know that this is an appropriate topic to bring up with their doctor.”
“The clinician often thinks, ‘if my patient had a symptom, she would tell me,’ ” Dr Kingsberg pointed out. “But women should not be expected to be the ones to go to their clinician and say, ‘I have vulvovaginal atrophy, and I’d like to be treated.’ “
For their study, Dr Kingsberg and colleagues invited 2424 ob/gyns and primary care physicians to complete a survey on their attitudes and behaviors related to vulvovaginal atrophy.
To be eligible, physicians had to work in a community-based practice, treat at least 15 patients a month with vulvovaginal atrophy, and see at least 50 (for ob/gyns) or 25 (for primary care physicians) menopausal women a month.
Participants received $23 for answering the 23 questions. Most respondents were men (64%) and were 40 to 59 years of age (66%).
Of the 945 respondents, 369 ob/gyns and 276 primary care physicians completed the survey.
The ob/gyns reported seeing an estimated 111 menopausal women per month, 55% of whom reported symptoms of vulvovaginal atrophy. Of the 99 menopausal women primary care physicians saw, on average, each month, 44% reported symptoms.
Overall, 49% of the women with vulvovaginal atrophy were prescribed treatment, 24% were advised to use an over-the-counter treatment, 14% were provided no treatment, 10% were advised to make a behavioral or lifestyle change to manage symptoms, and 3% were offered vaginal laser therapy.
Ob/gyns were more likely than primary care physicians to prescribe a therapy (53% vs 43%), and wrote more prescriptions each month (44 vs 35).
However, ob/gyns and primary care physicians were equally likely to prescribe medications on the basis of their effectiveness (77% ob/gyns vs 76% primary care physicians) or on the basis of out-of-pocket costs (33% vs 34%).
Ob/gyns and primary care physicians who prescribed medications for vulvovaginal atrophy were most likely to do so because of patient preference (28% vs 30%) and ease of use of the product (29% vs 28%).
However, ob/gyns were more likely than primary care physicians to disagree or strongly disagree that over-the-counter products are best for treating vulvovaginal atrophy (72% vs 47%).
The prescriptions chosen differed by specialty. Ob/gyns were more likely to prescribe estradiol vaginal cream (Estrace, Allergan), an estradiol vaginal insert (Vagifem, Novo Nordisk), an estrogen agonist/antagonist (Osphena, Duchesnay USA Inc), or an estradiol vaginal ring (Estring, Pfizer). In contrast, primary care physicians were more likely to prescribe conjugated estrogen (Premarin, Pfizer), dehydroepiandrosterone supplements, or compounded vaginal estrogens.
Table 1. Medications Prescribed for Vulvovaginal Atrophy
| Prescription | Ob/gyns, % | Primary Care Physicians, % |
| Estradiol vaginal cream | 31 | 25 |
| Estradiol vaginal insert | 15 | 12 |
| Estrogen agonist/antagonist | 9 | 7 |
| Estradiol vaginal ring | 6 | 5 |
| Conjugated estrogen | 30 | 38 |
| Compounded vaginal estrogen | 6 | 8 |
| DHEA supplement | 1 | 2 |
Further, “84% of the specialty physicians queried considered it important to use the lowest effective dose of hormone therapy when treating women experiencing [vulvovaginal atrophy] symptoms,” the researchers report.
Out-of-pocket costs were cited as a barrier to treatment by more ob/gyns than primary care physicians (64% vs 51%), as were concerns about risks related to estrogen therapy (59% vs 51%).
These were also the primary reasons women discontinued treatment, the respondents reported.
Table 2. Common Reasons Given for the Discontinuation of Treatment
| Reason | Ob/gyns, % | Primary Care Physicians, % |
| Cost | 77 | 61 |
| Symptom improvement | 52 | 59 |
| Concerns about long-term estrogen exposure | 47 | 54 |
Cost Barrier
“It’s nice when research confirms our biases, and my bias was that one of the biggest barriers to treating this is cost, because vaginal estrogens are typically not covered well,” said Karen Adams, MD, director of the menopause and sexual medicine program at Oregon Health & Science University in Portland.
“It’s incredibly frustrating, especially when their husbands’ testosterone patches are $2. It’s really quite appalling,” Dr Adams told Medscape Medical News.
Physicians have a responsibility to be transparent with patients about costs from the start, she added.
“It’s going to upset our patients if we write them something, they go to the pharmacy and it costs them $150, they call us back, and we’re clueless,” she explained. “We’re going to provide better care if we have the conversation with patients upfront.”
Dr Adams agrees with Dr Kingsberg that painful intercourse is not taken as seriously as it should be for such a burdensome medical problem.
“It’s really reflected in the billing codes,” she said. “The ‘dyspareunia’ code is typically not covered because it’s considered a lifestyle issue. ‘Dyspareunia due to a medical condition’ is usually better covered, but dyspareunia itself is a medical condition, so this distinction makes no sense at all.”
Clinicians do not pay enough attention to midlife sexuality, or female sexuality in general, said Dr Kingsberg.
“Vulvovaginal atrophy is a true medical condition, and it interferes with many things beyond sexuality,” she told Medscape Medical News. The tremendous economic costs of vulvovaginal atrophy and dyspareunia, and their potential to derail a relationship when not treated, have tremendous economic costs, she pointed out.
“What we know clinically is that when sex is good, it has about 20% added value, but when sex is bad, it is hugely, inordinately powerful, draining a relationship 50% to 70%,” Dr Kingsberg said. “Bad sex does way more to subvert an otherwise good relationship than good sex can support an average one. Across the board, it’s something we should treat.”
This research was funded by TherapeuticsMD. Dr Kingsberg holds stock in Viveve, is a speaker for Valeant, and has served as a consultant or on the advisory board of Amag Pharmaceuticals, Duchesnay, Emotional Brain, EndoCeutics, Materna Medical, Nuelle, Palatin Technologies, Pfzer, Shionogi, TherapeuticsMD, Valeant Pharmaceuticals, and Viveve. Dr Adams has disclosed no relevant financial relationships.
North American Menopause Society (NAMS) 2017 Annual Meeting: Abstract S9. Presented October 12, 2017.
Follow Medscape Ob/Gyn on Twitter @MedscapeObGyn and Tara Haelle @tarahaelle
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