Empowering the vaginal atrophy dialogue multi_therapeutic2

1,789 views

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,789
On SlideShare
0
From Embeds
0
Number of Embeds
9
Actions
Shares
0
Downloads
21
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • References
    North American Menopause Society. The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-369.
    Labrie F, Archer D, Bouchard C, et al. Intravaginal dehydroepiandrosterone (Prasterone), a physiological and highly efficient treatment of vaginal atrophy. Menopause. 2009;16(5):907-922.
    Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
  • Reference
    Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • Reference
    Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-522.
  • Vaginal environment before menopause and after estrogen loss.
    After the loss of estrogen:
    Vaginal epithelium becomes thinner
    Vaginal rugae diminish
    Vaginal wall appears smoother
    Vagina has pale appearance and may contain small petechiae and/or other signs of inflammation
    Vaginal elasticity is reduced
    Vaginal secretions decrease
    Reference
    Johnston SL. The Recognition and Management of Atrophic Vaginitis. Geriatrics & Aging. 2002; 5(7):9-15.
  • Changes to the lining of the vagina occur with menopause.
    Estrogen levels decrease during and after menopause, resulting in cytological changes:
    Proportion of parabasal cells increase
    Proportion of superficial cells decrease
    Lining of the vagina becomes thin and pale
    Vaginal walls also become smoother and less elastic due to decreasing rugal folds
    Reference
    North American Menopause Society (NAMS). The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-69.
  • References
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
  • Reference
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • References
    Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
  • Reference
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • References
    Sturdee DW, Panay N. The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Nappi RE, Kokot-Kierepa M. Vaginal health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • Reference
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • References
    Nappi RE. CLarifying vaginal atrophy’s impact On SEx and Relationships (CLOSER). European Menopause and Andropause Society (EMAS) Annual Congress, March 2012.
    Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
  • Reference
    Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
  • Reference
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • References
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
  • References
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • Reference
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • References
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • Reference
    Frank SM, Ziegler C, Kokot-Kierepa M, et al. Vaginal Health: Insights, Views & Attitude (VIVA) survey – Canadian cohort. Menopause Int. 2012 Nov 30. [Epub ahead of print]
  • References
    Society of Obstetricians and Gynaecologists of Canada. Chapter 5 – Urogenital Health. In: Menopause and Osteoporosis Update 2009. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30.
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Bélisle S, Blake J, Basson R, et al; Menopause Guidelines Committee. Canadian Consensus Conference on Menopause, 2006 update. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
  • References
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    North American Menopause Society (NAMS). The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-369.
    Bélisle S, Blake J, Basson R, et al; Menopause Guidelines Committee. Canadian Consensus Conference on Menopause, 2006 update. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
  • Reference
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • Reference
    Society of Obstetricians and Gynaecologists of Canada. Menopause and Osteoporosis Update 2009. J Obstet Gynaecol Can. 2009;31(1Suppl1):S27-S30.
  • References
    Vagifem® 10 product monograph. Mississauga, ON: Novo Nordisk Canada Inc.; September 13, 2010.
    Premarin® vaginal cream product monograph. Kirkland, QC: Pfizer Canada Inc.; February 20, 2012.
    Estragyn® vaginal cream product monograph. Concord, ON: Triton Pharma Inc.; July 21, 2011.
    Estring™ product monograph. Kirkland, QC: Pfizer Canada Inc.; June 29, 2009.
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Rioux JE, Devlin C, Gelfand MM, et al. 17 β-estradiol vaginal tablet versus conjugated equine estrogen vaginal cream to relieve menopausal atrophic vaginitis. Menopause. 2000;7(3):156-61.
    Ayton RA, Darling GM, Murkies AL, et al. A comparative study of safety and efficacy of continuous low-dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Br J Obstet Gynaecol. 1996;103(4):351-8.
  • Reference
    Simon J, Nachtigall L, Gut R, et al. Effective treatment of vaginal atrophy with an ultra–low-dose estradiol vaginal tablet. Obstet Gynecol. 2008;112(5):1053-60.
  • References
    Vagifem 10 [product monograph]. Mississauga, Ontario: Novo Nordisk Canada Inc.; 2010.
    Simon J, Reape K, Hait H. Evaluation of bleeding patterns during twelve weeks of treatment with unopposed synthetic conjugated estrogens-B and following progestin withdrawal. The 18th Annual Meeting of the North American Menopause Society (NAMS). Orlando, Florida. September 24-27, 2008.
  • Reference
    Simon J, Nachtigall L, Gut R, et al. Effective treatment of vaginal atrophy with an ultra–low-dose estradiol vaginal tablet. Obstet Gynecol. 2008;112(5):1053-60.
  • Reference
    Simon J, Nachtigall L, Gut R, et al. Effective treatment of vaginal atrophy with an ultra–low-dose estradiol vaginal tablet. Obstet Gynecol. 2008;112(5):1053-60.
  • Reference
    Simon J, Nachtigall L, Gut R, et al. Effective treatment of vaginal atrophy with an ultra–low-dose estradiol vaginal tablet. Obstet Gynecol. 2008;112(5):1053-60.
  • Reference
    Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
  • Reference
    Gingras L, Moreau M, Manno P, et al. Impact of vulvovaginal atrophy on postmenopausal women and their partners: The Partner’s Survey. SOGC 68th Annual Conference, Ottawa, ON June 2012. Poster 486. Available at: http://posterdocuments.com/posters/v/id/486. Accessed March 17, 2013.
  • Reference
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • Reference
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • References
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    North American Menopause Society (NAMS). The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007;14(3):357-69.
  • References
    Society of Obstetricians and Gynaecologists of Canada. Menopause and Osteoporosis Update 2009. J Obstet Gynaecol Can. 2009;31(1Suppl1):S27-S30.
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • References
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
    Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012;15:36-44.
  • Reference
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • Reference
    Sturdee DW, Panay N; The International Menopause Society Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric. 2010;13:509-22.
  • Empowering the vaginal atrophy dialogue multi_therapeutic2

    1. 1. Empowering the Vaginal Atrophy Dialogue
    2. 2. Faculty/Presenter Disclosure  Faculty: Dr. Unjali Malhotra  Relationships with commercial interests:  Grants/Research Support: none  Speakers Bureau/Honoraria: Bayer, Merck, Pfizer, Novo Nordisk  Consulting Fees: Pfizer  Other: none
    3. 3. Disclosure of Commercial Support  This program has received financial support from Novo Nordisk in the form of an educational grant  Potential for conflict(s) of interest:  Dr. Unjali Malhotra has received an honorarium from Novo Nordisk whose product(s) are being discussed in this program  Novo Nordisk distributes, licenses a product that will be discussed in this program: Estradiol 10 μg (Vagifem® 10)
    4. 4. Mitigating Potential Bias  Material was developed and reviewed by independent third-party experts who were responsible for vetting the program’s needs assessment results and subsequent content development to ensure accuracy and fair balance
    5. 5. Learning Objectives  After this session, participants will be able to:  Describe the prevalence and pathophysiology of vaginal atrophy  Discuss women’s attitudes about vaginal atrophy  Examine the effects of vaginal atrophy and its treatment on intimate relationships  Manage vaginal atrophy using the latest treatment recommendations  Counsel post-menopausal women about vaginal atrophy and treatment options
    6. 6. Pre-Test Questions 1. In vaginal atrophy : A. Vaginal pH decreases B. Blood flow is maintained C. Parabasal cells predominate in the epithelium D. Inflammation is always absent
    7. 7. Pre-Test Questions 2. Post-menopausal Canadian women: A. Have a good understanding of vaginal atrophy and its associated symptoms B. Are aware of the chronic nature of the condition C. Are likely to use over-the-counter products before discussing symptoms with their physicians D. More than 40% would be willing to use local vaginal estrogen to treat vaginal atrophy symptoms E. All of the above F. C and D
    8. 8. Pre-Test Questions 3. Local estrogen therapy: A. Effectively manages symptoms B. Reverses atrophic changes C. Has a positive impact on intimate relationships D. All of the above E. A and B
    9. 9. Pre-Test Questions 4. How comfortable are you discussing treatment options for vaginal atrophy with post-menopausal women? A. Very uncomfortable B. Somewhat uncomfortable C. Somewhat comfortable D. Very comfortable
    10. 10. Prevalence of Vaginal Atrophy  Up to 75% of menopausal women may experience vaginal atrophy symptoms1,2  Approximately 50% of post-menopausal women have vaginal atrophy symptoms that impact on sexual function and quality of life3  Despite its prevalence, vaginal atrophy is often not recognized by women as a chronic condition  1/3 will not seek medical advice3  The taboo status surrounding vaginal atrophy means that many women do not receive effective treatment 1. The North American Menopause Society. Menopause. 2007;14:357-369. 2. Labrie F, et al. Menopause. 2009;16:907-22. 3. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
    11. 11. IMS Recommendations: Background Post-menopausal vaginal atrophy: A common cause of distressing symptoms due to estrogen deficiency Poorly recognized by healthcare professionals Should be diagnosed and treated promptly to avoid cascade of events that do not resolve spontaneously IMS, International Menopause Society. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    12. 12. Vaginal Atrophy Pathophysiology: Effects of Declining Estrogen  Vaginal epithelium becomes thinner, vaginal rugae diminish  Vaginal wall appears smoother  Colonization of the vagina by lactobacillus decreases  Vaginal pH rises above 6  Blood flow is reduced  Vagina has pale appearance and may contain small petechiae and/or other signs of inflammation Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    13. 13. Vaginal Atrophy: Pathophysiology Johnston SL. Geriatrics & Aging. 2002;5(7):9-15. Vaginal environment before menopause Vaginal environment after estrogen loss Ovaries produce less estrogen (or none at all)Ovaries produce estrogen The vaginal lining is thick and moist The vaginal lining becomes thin and dry There is decreased blood flow to vaginal tissues There is good blood flow to vaginal tissues Vaginal walls are elastic Vaginal fluid is secreted during sexual activity Vaginal elasticity decreases There is less secretion of fluids during sexual activity The vagina narrows and shortens
    14. 14. Vaginal Atrophy Pathophysiology: Cellular Changes Thick, healthy, well-estrogenized lining of the vagina in premenopausal women Thin, dry lining of vagina due to menopause (after estrogen loss) superficial parabasal intermediate The North American Menopause Society. Menopause. 2007;14:357-69. After menopause, there is an increase in parabasal and intermediate cells and a substantial decrease in superficial cells Intermediate and superficial cells predominate in premenopausal women; minimal parabasal cells
    15. 15. Discussion Question  What do post-menopausal Canadian women know about vaginal atrophy?
    16. 16. Viva Survey Results: What Do Post-menopausal Canadian Women Know About Vaginal Atrophy?  Most women thought vaginal dryness, itching, burning, soreness, or pain during intercourse were merely symptoms of menopause  Only 7% of Canadian women associated these symptoms with vaginal atrophy VIVA, Vaginal Health: Insights, Views & Attitudes. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    17. 17. VIVA Survey Results: How Many Women Experience Symptoms of Vaginal Atrophy? VIVA, Vaginal Health: Insights, Views & Attitudes. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print] 50% of Canadian women experienced vaginal symptoms 59% rated these symptoms as moderate or severe
    18. 18. Discussion Question Which of the following is not a symptom of vaginal atrophy? A.Dryness B.Incontinence C.Pain during intercourse D.Itching E.Vaginal discharge F.All are symptoms of vaginal atrophy
    19. 19. Recognizing the Symptoms of Vaginal Atrophy  The most common vaginal atrophy symptoms reported in the IMS recommendations1 are the same as those reported by women in the VIVA survey2  Dryness (estimated 75%)1  Dyspareunia (estimated 38%)1  Vaginal itching, discharge, pain (estimated 15%)1  Urinary symptoms associated with vaginal atrophy:1  Dysuria, nocturia, and urgency  Urinary incontinence  Recurrent urinary tract infections IMS, International Menopause Society. VIVA, Vaginal Health: Insights, Views & Attitudes. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
    20. 20. VIVA Survey Results: Which Symptoms of Vaginal Atrophy Do Canadian Women Experience? VIVA, Vaginal Health: Insights, Views & Attitudes. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print] Dryness was by far the most commonly experienced symptom of vaginal atrophy
    21. 21. In Her Own Words… About Her Symptoms Play video Joan Boone TRANSCRIPT OF VIDEO CLIP: “Vaginal atrophy has so many symptoms, but not every woman has every symptom. The ones I had were dryness, a loss of natural moisturizer; I had painful intercourse, and I had really just the driest feeling, so it was uncomfortable.”
    22. 22. Discussion Question  How does vaginal atrophy impact the lives of post-menopausal women?
    23. 23. IMS Recommendations: Be Aware That Women Are Suffering in Silence  Women are often reluctant to consult/complain about vaginal atrophy, and they may feel their doctors are also uninterested or uncomfortable talking about this issue1,2  The Canadian cohort of the VIVA survey also demonstrated this3 IMS, International Menopause Society. VIVA, Vaginal Health: Insights, Views & Attitudes. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44. 3. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print] “We don’t have a pink Viagra for women,” says Dr. Rossella Nappi. “… maybe it’s less easy to treat VA because it’s easy to speak about ED, and it’s not so easy to talk about VA. We should talk about ED and VA together for a better life of the couple.” ZOOMER Magazine, March 2013
    24. 24. Canadian Women Are Suffering in Silence  52% of women with vaginal atrophy waited ≥6 months before seeing a healthcare provider  56% of women experiencing vaginal atrophy had symptoms ≥3 years Length of time women experienced symptoms of vaginal discomfort Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    25. 25. CLOSER Survey Results: Effects of Vaginal Atrophy on How a Woman Feels About Herself  51% of women felt upset that their body doesn’t work as well anymore  41% of women felt they had lost their youth  33% of women were concerned that vaginal atrophy would never go away  27% women had lost confidence in themselves as a sexual partner and no longer felt sexually attractive CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships. Nappi RE. European Menopause and Andropause Society (EMAS) Annual Congress, March 2012. Gingras L, et al. SOGC 68th Annual Conference. June 2012. Poster 486.
    26. 26. 58% 49% 35% 23% 62%61% 28% 14% 22% 76% 0% 10% 20% 30% 40% 50% 60% 70% 80% Less sex Less satisfying sex Put off having sex Stopped having sex altogether Avoided intimacy Respondents,% Women Men CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships. Gingras L, et al. SOGC 68th Annual Conference. June 2012. Poster 486. CLOSER Survey: Effects of Vaginal Discomfort on Intimate Relationships (Canadian Data)
    27. 27. VIVA Survey Results: Who Would Canadian Women Turn to if They Experienced Vaginal Discomfort?  60% of women were comfortable discussing vaginal atrophy with their doctor  72% of Canadian women would talk to their primary care physician if they experienced vaginal discomfort  30% would speak to their gynecologist The Physician-Patient conversation about vaginal atrophy needs to be routine VIVA, Vaginal Health: Insights, Views & Attitudes. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    28. 28. Discussion Question  How would you start the vaginal atrophy conversation?
    29. 29. IMS Recommendations: Getting the Conversation Started  Talk about vaginal dryness since patients may be reluctant to do so1  Consider that relationship/sexual issues may present as vaginal discomfort1  In the CLOSER Survey, 27% of Canadian women said vaginal atrophy made them lose confidence in themselves as a sexual partner2  Remember that women using systemic estrogen can still develop vaginal atrophy symptoms1  Some urinary symptoms occur concurrently with vaginal atrophy and also respond positively to vaginal estrogen therapy1 IMS, International Menopause Society. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. Gingras L, et al. SOGC 68th Annual Conference. June 2012. Poster 486.
    30. 30. IMS Recommendations: Getting the Conversation Started  Ask questions such as:  “Around the time of menopause, some women may experience vaginal dryness, which may make intercourse uncomfortable. Have you noticed this type of change?”  Be sensitive to the presence of an able sexual partner  “Are you bothered by vaginal itching or vaginal burning?”  “Have you noticed a change in vaginal discharge?”  “Do you sometimes or often have vaginal yeast infections?”  “Do you sometimes or often have urinary tract infections?”  “Have you ever taken any vaginal lubricants or moisturizers to relieve vaginal dryness or itching?” IMS, International Menopause Society. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    31. 31. VIVA Survey Results: Canadian Women More Likely to Use OTC Products Than Treat Underlying Cause HRT, hormone replacement therapy. OTC, over-the-counter. VIVA, Vaginal Health: Insights, Views & Attitudes. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    32. 32. IMS Recommendations and VIVA Survey: Treatment Options  Women need to be informed about effective treatment options for vaginal atrophy1  VIVA survey data revealed women’s lack of knowledge about treatment options  Close to 1 in 10 women believed there is no effective treatment for vaginal discomfort2  In Canada, 42% of women were unaware of local estrogen treatments3 IMS, International Menopause Society. VIVA, Vaginal Health: Insights, Views & Attitudes. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44. 3. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    33. 33. VIVA Survey Results: Canadian Women Willing to Try Effective Treatment That Maintains Normal Hormone Levels  Only 32% would consider systemic hormone replacement therapy  43% were willing to try local estrogen treatment (LET)  24% undecided about using LET  65% Canadian women did not expect return to the vagina of their youth, but would welcome greater comfort VIVA, Vaginal Health: Insights, Views & Attitudes. Frank SM, et al. Menopause Int. 2012 Nov 30. [Epub ahead of print]
    34. 34. Discussion Questions  What are the available treatment options for vaginal atrophy?
    35. 35. IMS and SOGC Recommendations: Vaginal Moisturizers and Lubricants Vaginal lubricants May be recommended for subjective symptom improvement of dyspareunia (Level IIIC evidence)1 Do not reverse vaginal atrophy1 Are non-physiological2 Give temporary symptom relief, often followed by vaginal irritation2 Vaginal moisturizers Polycarbophil gel is an effective treatment for symptoms of vaginal atrophy, including dryness and dyspareunia (Level IA evidence)1 Improve lubrication2 Do not reverse vaginal atrophy3 Are less effective than topical estrogen therapy2 Are useful for women who cannot take hormones2 IMS, International Menopause Society. SOGC, Society of Obstetricians and Gynaecologists of Canada. 1. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30. 2. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 3. Bélisle S, et al; Menopause Guidelines Committee. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
    36. 36. IMS Recommendations: Principles of Local Estrogen Therapy  Restore urogenital physiology1-3  Estrogen therapy lowers vaginal pH, thickens the epithelium, increases blood flow, improves vaginal lubrication1  Alleviate symptoms1-3  Most women will obtain substantial relief from their symptoms after about 3 weeks of treatment1  Some women may require 4–6 weeks before adequate improvement is observed1  These principles are also supported by NAMS and SOGC2,3 IMS, International Menopause Society. NAMS, North American Menopause Society. SOGC, Society of Obstetricians and Gynaecologists of Canada. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. North American Menopause Society. Menopause. 2007;14(Pt 1):357-69. 3. Bélisle S, et al; Menopause Guidelines Committee. J Obstet Gynaecol Can. 2006;28(2 Suppl 1):S7-S94.
    37. 37. IMS Recommendations: Local Estrogen Therapy  Local estrogen therapy is preferable for vaginal atrophy when systemic treatment is not needed for other reasons  Systemic and local therapy may be initially required for some women  Local therapy avoids most systemic adverse events and is probably more efficacious for vaginal problems IMS, International Menopause Society. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. Vaginal cream with applicator Intravaginal ring Vaginal tablet with applicator
    38. 38. SOGC Recommendations: Local Estrogen Therapy SOGC Clinical Practice Guidelines Conjugated estrogen cream, an intravaginal sustained-release estradiol ring, or estradiol vaginal tablets can be recommended as effective treatment for vaginal atrophy (Level IA) Vaginal estrogen therapy can be recommended for the prevention of recurrent urinary tract infections in post-menopausal women (Level IA) SOGC, Society of Obstetricians and Gynaecologists of Canada. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30.
    39. 39. Vaginal Atrophy Treatment: Local Estrogen Therapies Available in Canada Formulation Vaginal Tablet Vaginal Cream Vaginal Ring Estrogen type (trade name) Estradiol 10 μg (Vagifem® 10)1 Conjugated estrogens 0.625 mg/g (Premarin® )2 Estrone 0.1% (Estragyn® )3 17 ß-Estradiol 2 mg (Estring™)4 Dose • 1 vaginal tablet • Start at 0.5 g daily dose strength • Dose adjustments (0.5 to 2 g) may be made based on individual response • 2.0 to 4.0 g per day • 1 ring/3 months Dosage • Initial: daily for 2 weeks • Maintenance: twice a week with a 3-4 day interval between doses • Daily for 21 days, then 7 days off • Daily for 25 days, then 5 days off • 1 ring should remain inserted in the vagina for 90 days Administration • Each tablet is in a pre- loaded applicator ready to be inserted into the vagina • Cream needs to be squeezed into the applicator and dose measured prior to administration • 1 ring inserted into the vagina 1. Vagifem® 10 product monograph. 2010. 2. Premarin® product monograph. 2012. 3. Estragyn® product monograph. 2011; 4. Estring™ product monograph. 2009. 5. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 6. Rioux JE, et al. Menopause. 2000;7(3):156-61. 7. Ayton RA, et al. Br J Obstet Gynaecol. 1996;103(4):351-8.  All local estrogen preparations are effective5  Patient preference usually determines treatment used5  Patients prefer vaginal tablets and rings over cream6,7
    40. 40. Local Estrogen Therapy: Effect on Vaginal Epithelium Improvement in vaginal epithelium maturation LOCF, last observation carried forward. Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60. * * ** * ** * * * * * * * * * * *p<0.001 10 µg estradiol vs. placebo. **p=0.007 10 µg estradiol vs. placebo. Placebo 10 µg Estradiol 2
    41. 41. Local Estrogen Therapy: Effect on pH pH <5 = grade 0 (no vaginal atrophy) pH 5–5.49 = grade 1 (mild vaginal atrophy) pH 5.5–6.49 = grade 2 (moderate vaginal atrophy) pH >6.49 = grade 3 (severe vaginal atrophy) P-values describe comparisons of the change from baseline between treatment groups. LOCF, last observation carried forward. 1. Vagifem® 10 product monograph. 2010. 2. Simon JA, et al. 18th Annual Meeting of the North American Menopause Society (NAMS). 2008. Improvement (lowering) of vaginal pH
    42. 42. Local Estrogen Therapy: Effect on Vaginal Health Grading vaginal health Evaluations of:  Vaginal secretions  Epithelial integrity  Epithelial surface thickness  Vaginal colour  Vaginal pH Coded on 4-point scale:  No atrophy = 0  Mild atrophy = 1  Moderate atrophy = 2  Severe atrophy = 3 Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60.
    43. 43. Local Estrogen Therapy: Effect on Vaginal Health P-values describe comparisons of the change from baseline between treatment groups. LOCF, Last observation carried forward. Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60. Improvement in vaginal health p<0.001 p<0.001 p<0.001 p<0.001 p<0.001
    44. 44. Local Estrogen Therapy: Effect on Bothersome Symptoms p=0.053 p=0.014 p=0.003 p=0.004 P-values describe comparisons of the change from baseline between treatment groups. LOCF, Last observation carried forward. Simon J, et al. Obstet Gynecol. 2008;112(5):1053-60. Change in most bothersome symptom score 0.0 0.5 1.0 1.5 2.0 2.5 Baseline 2 4 8 12 (LOCF) 52 (LOCF) Meanscore Mostbothersomesymptom Weeks Placebo 10 µg Estradiol 2
    45. 45. Local Estrogen Therapy: Effects on Sex Life (CLOSER Survey, Canadian Data)  Canadian women with vaginal atrophy reported that since starting local estrogen therapy:  Sex was less painful (58%)  Sex was more satisfying for them personally (43%)  They were more optimistic about the future of their sex life (33%)  Their sex life had improved (32%)  Canadian men reported that since their partner started local estrogen therapy for vaginal atrophy:  Sex was less painful (58%)  They look forward to having sex (59%) CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships. Gingras L, et al. SOGC 68th Annual Conference. June 2012. Poster 486.
    46. 46. Local Estrogen Therapy: Effects on Sex Life (CLOSER Survey, Canadian Data) CLOSER, CLarifying Vaginal Atrophy’s Impact On SEx and Relationships. Gingras L, et al. SOGC 68th Annual Conference. June 2012. Poster 486.
    47. 47. In Her Own Words… About Her Treatment Play Video Joan Boone TRANSCRIPT OF VIDEO CLIP: “I find that it’s treated all my symptoms, it’s improved my vaginal health, it’s improved my home life with my husband because I’m not having the same kind of problems that I was previously.”
    48. 48. For Discussion Which of the following conditions is not a contraindication for treatment with local estrogen therapy? A.Undiagnosed vaginal/uterine bleeding B.Interstitial cystitis C.Known or suspected endometrial cancer D.Other hormone-sensitive cancers
    49. 49. Local Estrogen Therapy: Contraindications  Treatment is contraindicated in patients with:  Undiagnosed vaginal/uterine bleeding  Known or suspected endometrial cancer  Other hormone-sensitive cancers Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    50. 50. Local Estrogen Therapy: Adverse Effects  Few adverse events  Vaginal discharge, itching, irritation, and pelvic pain may be more common with creams  Systemic effects are uncommon  Endometrial hyperplasia and breast tenderness may be more common with creams  Women need to report vaginal bleeding and breast tenderness, as these side effects are not anticipated with low-dose vaginal therapy Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    51. 51. Local Estrogen Therapy (LET): Adverse Effects (cont’d)  No evidence of increase in VTEs with use of LET1  No evidence of increase in metastases in breast cancer survivors using LET1  For women with a history of hormone-dependent cancer:  Management should depend on patient preference in consultation with oncologist2  For women treated for non-hormone-dependent cancer:  Management of vaginal atrophy is similar to that for women without a cancer history2  Data insufficient to recommend annual endometrial surveillance in asymptomatic women2 VTE, venous thromboembolism. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. The North American Menopause Society. Menopause. 2007;14:357-69.
    52. 52. Local Estrogen Therapy: Is Progestin Required? SOGC Clinical Practice Guidelines:1 Routine progestin co-therapy is not required for endometrial protection in women receiving vaginal estrogen therapy in appropriate dose (IIIC) IMS recommendations:2 Conjugated estrogen and estradiol vaginal preparations may stimulate the endometrium in a dose-related manner Appropriate use of low doses of local estrogen does not require additional progestin for endometrial protection IMS, International Menopause Society. SOGC, Society of Obstetricians and Gynaecologists of Canada. 1. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can. 2009;31(1 Suppl 1):S27-S30. 2. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    53. 53. Local Estrogen Therapy: Treatment Duration  There are no guidelines for therapy duration1  There are limited data on use of local estrogen beyond 6 months  Symptoms commonly return when treatment is discontinued1  If long-term therapy is going to be implemented, low-dose therapy should be used1  Women need to be informed that long-term treatment may be needed1  In the VIVA survey, more than 6 in 10 women did not know that vaginal atrophy is a chronic condition2  Treatment failure should mandate further evaluation1 VIVA, Vaginal Health: Insights, Views & Attitudes. 1. Sturdee DW, Panay N. Climacteric. 2010;13:509-22. 2. Nappi RE, Kokot-Kierepa M. Climacteric. 2012;15:36-44.
    54. 54. IMS Key Treatment Recommendations 1. Start treatment early, before irrevocable atrophic changes have occurred 2. Continued treatment is needed to maintain the benefits 1. All local estrogen preparations are effective 2. Patient preference will usually determine the treatment that is used IMS, International Menopause Society. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    55. 55. IMS Key Treatment Recommendations 5. Additional progestin is not indicated when appropriate low-dose, local estrogen is used, although long-term data (more than 1 year) are lacking 6. If estrogen is ineffective or undesired, vaginal lubricants and moisturizers can relieve symptoms due to dryness 7. It is essential that healthcare providers routinely engage in open and sensitive discussions with post-menopausal women about their urogenital health to ensure that symptomatic atrophy is detected early and managed appropriately IMS, International Menopause Society. Sturdee DW, Panay N. Climacteric. 2010;13:509-22.
    56. 56. Summary: Key Learning Points  Vaginal atrophy is a common, chronic condition that can have a significant effect on a woman’s quality of life  Women suffer in silence, are reluctant to initiate a dialogue about their symptoms, and are unaware that effective treatments are available  There is a need to normalize this condition  Treatment with local estrogen is simple and safe and can transform a woman’s quality of life including intimate relationships  43% of Canadian women are open to treatment with local estrogen therapy that maintains normal hormone levels  Physicians need to routinely discuss and effectively manage the symptoms of vaginal atrophy in post-menopausal women
    57. 57. Post-Test Questions 1. In vaginal atrophy: A. Vaginal pH decreases B. Blood flow is maintained C. Parabasal cells predominate in the epithelium D. Inflammation is always absent
    58. 58. Post-Test Questions 2. Post-menopausal Canadian women: A. Have a good understanding of vaginal atrophy and its associated symptoms B. Are aware of the chronic nature of the condition C. Are likely to use over-the-counter products before discussing symptoms with their physicians. D. More than 40% would be willing to use local vaginal estrogen to treat vaginal atrophy symptoms E. All of the above F. C and D
    59. 59. Post-Test Questions 3. Local estrogen therapy: A. Effectively manages symptoms B. Reverses atrophic changes C. Has a positive impact on intimate relationships D. All of the above E. A and B
    60. 60. Post-Test Questions 4. How comfortable are you discussing treatment options for vaginal atrophy with post-menopausal women? A. Very uncomfortable B. Somewhat uncomfortable C. Somewhat comfortable D. Very comfortable

    ×