CLIMACTERIC 2012;15:3644

Vaginal Health: Insights, Views & Attitudes (VIVA) results from an international survey
R. E. Nappi and M. Kokot-Kierepa*
Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause Unit, Department of Obstetrics and Gynecology, IRCCS S Matteo Foundation, University of Pavia, Pavia, Italy; *Novo Nordisk FemCare AG, Zurich, Switzerland Key words: ATTITUDE, MENOPAUSE, POSTMENOPAUSE, SURVEY, VAGINAL ATROPHY, VAGINAL HEALTH

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ABSTRACT
Objective To assess knowledge of vaginal atrophy among women using the Vaginal Health: Insights, Views & Attitudes (VIVA) survey. Methods A structured online questionnaire was used to obtain information from 3520 postmenopausal women aged 5565 years living in Great Britain, the United States, Canada, Sweden, Denmark, Finland, and Norway. Results In total, 45% of women reported experiencing vaginal symptoms. Only 4% of women attributed these symptoms to vaginal atrophy, and 63% failed to recognize vaginal atrophy as a chronic condition. Overall, 44% of respondents did not have a gynecologist, but this percentage varied between countries. Most women (75%) felt that vaginal atrophy had a negative impact on life, but this perception also showed country-specic differences. Most Finnish respondents (76%) were satised with the amount of information available about vaginal atrophy, compared with just 3742% of women from other countries. Most women used over-the-counter products for vaginal atrophy symptoms, but specic means of treating the underlying cause were less well known. Almost half (46%) of all respondents lacked knowledge about local estrogen therapy, with women in Great Britain, the United States and Canada being most likely to lack knowledge of such treatment. Overall, 30% of women would consider taking local estrogen therapy, with vaginal tablets being the preferred option in all countries. Conclusion Postmenopausal women have a low understanding of vaginal atrophy. Medical practitioners should proactively raise this topic, help patients to understand that vaginal atrophy is a chronic condition, and discuss treatment options. Country-specic approaches may be required.

INTRODUCTION
Ovarian failure during menopause produces a marked decline in estrogen levels that affects many organ systems1. However, the urogenital tract specically, the vagina, urethra, bladder, trigone and pelvic oor muscles2 is particularly sensitive to estrogen deprivation1, and a lack of local estrogen is the primary cause of atrophy in these tissues and structures3. As a result, approximately 50% of postmenopausal women will experience symptoms relating to urogenital atrophy, with subsequent impact on sexual function and quality of life1. Vaginal atrophy associated with estrogen depletion becomes clinically apparent 45 years after the menopause1. Chronic reduction in estrogen levels ultimately leads to vaginal

dryness2, resulting from reduced transudation through the vaginal epithelium and reduced cervical gland secretions. Indeed, when vaginal atrophy is present in menopausal women, vaginal dryness is commonly the rst symptom reported4. The number of women reporting vaginal dryness increases from early to late perimenopause5, and the prevalence subsequently increases as women advance through the postmenopausal years1. Other symptoms of vaginal atrophy typically include irritation, itching, discharge and, among sexually active women, dyspareunia and other forms of sexual dysfunction1,6. In addition, urinary symptoms (such as frequency, urgency, nocturia, dysuria, incontinence and recurrent infections)7,8 occur more frequently when vaginal atrophy is present. In a United States-based survey of women

Correspondence: Professor R. E. Nappi, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause Unit, Department of Obstetrics and Gynecology, IRCCS S Matteo Foundation, University of Pavia, Piazzale Golgi 2, 27100 Pavia, Italy

ORIGINAL ARTICLE 2012 International Menopause Society DOI: 10.3109/13697137.2011.647840

Received 25-08-2011 Revised 07-11-2011 Accepted 20-11-2011

Vaginal health survey aged 45 years or older, 60% of past or non-users of menopausal hormone therapy had experienced vaginal symptoms, with over 90% reporting them to be bothersome9. Despite the high prevalence and diversity of symptoms associated with vaginal atrophy, and despite their marked impact on sexual function and quality of life, only around onequarter of symptomatic women seek medical help10. Women are often reluctant to consult their doctors about vaginal symptoms, perhaps due to embarrassment, cultural values, or acceptance of such symptoms as an inevitable consequence of aging1,2. Furthermore, many women might not be fully aware of the link between vaginal discomfort and declining estrogen levels1, or may be concerned about withdrawal bleeding and the possible increased risk of breast cancer associated with long-term estrogen use10, particularly with systemic therapies. However, providing women with an opportunity to talk about sexual health is a fundamental aspect of good health care11, and most women express relief and respond positively when health-care professionals initiate such discussions1. Furthermore, the treatment of vaginal atrophy has positive effects on womens general and sexual quality of life12,13. Medical practitioners should therefore initiate and engage in open, sensitive dialogue with postmenopausal women about this aspect of their health1, so that symptomatic vaginal atrophy can be detected early and appropriate management initiated before irreversible atrophic changes occur1. In a recently reported survey involving interviews with 4246 women aged 5565 years living in Sweden, Finland, the United Kingdom, the United States and Canada, we reported that, although 39% of the postmenopausal cohort had experienced vaginal atrophy, 77% of the interviewees believed that women were uncomfortable discussing the condition and 42% were unaware of the availability of local treatment14. This article presents the results of the new Vaginal Health: Insights, Views & Attitudes (VIVA) survey, which was conducted in Europe and North America to further explore womens knowledge regarding vaginal health and, in particular, vaginal atrophy. The goals of this survey are to increase awareness of this condition, facilitate physicianpatient dialogue, and thus provide the opportunity for women with vaginal atrophy to make better-informed treatment decisions.

Nappi and Kokot-Kierepa awareness of relevant issues (e.g. media coverage and internetbased information, such as websites and patient discussion forums), with the Scandinavian countries being perceived as more liberal and progressive in this regard14. Great Britain, the United States, and Canada were included as a representative sample of English-speaking countries. This quantitative, internet-based survey used a structured online questionnaire to obtain basic demographic information from participants, and to assess respondents knowledge of vaginal atrophy and sources of information and advice. The questions also aimed to collect information regarding womens awareness, perceptions, and experience of treatment options for vaginal atrophy. The questionnaire considered various aspects of vaginal atrophy, which was referred to as vaginal discomfort and dened as dryness, itching, burning or soreness in the vagina, involuntary urination, or vaginal pain in connection with touching and/or intercourse. The questions used to collect information on vaginal atrophy, its treatment, and respondents perceptions of the condition are presented in Table 1. Various measures were employed to ensure the quality of the data and to remove any potential bias. Potential respondents were asked a series of screening questions to ensure eligibility to participate in the survey. The data from the respondents were then thoroughly checked, and any nonsensical responses or questionnaires which had been completed too quickly were discounted. Data from 3520 respondents (500 participants each from Great Britain, the United States, Canada, Sweden, Denmark and Finland, and 520 from Norway) were summarized descriptively. Results are described here for the total population, with country-specic differences in responses highlighted where appropriate.

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RESULTS Survey population

The demographic characteristics of the survey population are given in Supplementary Table 1 to be found online at http:// www.informahealthcare.com/cmt/doi/10.3109/13697137. 2012.647840. The majority of women surveyed (67%) had their last menstrual cycle more than 5 years previously; most were married (58%) and lived in cities or towns (51%). Overall, 44% did not have a gynecologist, but this percentage showed marked variation between different countries: the majority of respondents from Great Britain (73%) did not have a gynecologist, compared with just 15% of those in Finland. Additionally, more women in Finland (62%) than in any other sampled country had access to a female gynecologist.

METHODS
The VIVA survey was carried out during August 2010 by StrategyOne (London, UK). As an independent market research organization, StrategyOne selected survey respondents from pre-recruited panels of individuals who had opted to participate in surveys via e-mail, so as to obtain a representative sample of women. No nancial incentive was offered. To take part in the VIVA survey, the women were required to be aged 5565 years, to have reached the menopause and ceased menstruating for 12 months, and to be living in Great Britain, the United States, Canada, Sweden, Denmark, Finland, or Norway. These countries were chosen to reect differences not only in health-care systems, but also in cultural attitudes and country-specic initiatives to increase patients

Vaginal atrophy
Overall, 45% of survey respondents reported experiencing some form of vaginal symptom of menopause (Figure 1). This gure ranged from 38% in Sweden to 51% in the United States. Most women attributed these symptoms to conditions other than

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Vaginal health survey

Table 1 Questions included in the survey on vaginal discomfort*

Nappi and Kokot-Kierepa

Symptom occurrence, severity and effects Which symptoms of the menopause have you experienced? If you experienced dryness, itching, burning, soreness in your vagina, or pain during intercourse, which condition(s) would you think you had? If you experienced dryness, itching, burning, soreness in your vagina, or pain during intercourse, which term do you think is the most suitable to describe this? Have you experienced vaginal discomfort since you stopped menstruating? For respondents who had experienced vaginal discomfort since the menopause: Which symptom(s) of vaginal discomfort have you experienced since you stopped menstruating? Overall, how severe would you describe the symptom(s) of vaginal discomfort you experienced? For how long have you experienced symptoms of vaginal discomfort? How concerned or not concerned are or were you about the symptoms of the menopause? Generally speaking, do you think vaginal discomfort is an acute or a chronic condition? Which word(s) or phrase(s) do you think describe(s) how a woman might feel about herself when having symptoms of vaginal discomfort? How do you think vaginal discomfort affects womens lives in general? Which area(s) of a womans life do you feel is/are negatively impacted by vaginal discomfort? Information sources and advice Do you think there is enough information available about the symptoms and treatment of vaginal discomfort? From which source(s) have or would you obtain information to understand your symptoms and/or treatment options for vaginal discomfort? How do or would you feel about speaking to your doctor about vaginal discomfort? How strongly do you agree or disagree with the following? My doctor did not discuss with me what it means to have a healthy vagina after menopause. For respondents who had experienced vaginal discomfort since the menopause: Which health-care professional(s) did you go to for treatment when you experienced vaginal discomfort? For respondents who had experienced vaginal discomfort since the menopause and who had consulted a health-care professional for their symptoms: For how long did you experience the symptoms of vaginal discomfort before seeing a health-care professional? Treatment Which treatment(s) are you aware of for the effective treatment of vaginal discomfort? For respondents who had experienced vaginal discomfort since the menopause: Which treatment(s) have you used to treat your symptoms of vaginal discomfort? Which consequence(s) do you associate with HRT oral tablets or patches? Would you consider taking HRT oral tablets and/or patches to treat vaginal discomfort, if you knew they were effective and would keep your hormone levels normal? Which consequence(s) do you associate with local estrogen therapy? Would you consider taking local estrogen therapy, which is a small amount of estrogen in the form of tablets, vaginal creams, vaginal suppositories or a ring inserted into the vagina to treat vaginal discomfort, if you knew it was effective and would keep your hormone levels normal? How strongly do you agree or disagree with the following? I am not expecting to return to the vagina of my youth; however, I would welcome greater comfort. How strongly do you agree or disagree with the following? I want to have the freedom to be the woman I want, independently of age. Note: The questions shown above are grouped according to their presentation in this article, which is not necessarily indicative of the order in which they were asked in the survey. Respondents were able to select answers to each question from a list, with more than one answer being permissible in some instances. The survey used questionnaires in the local language HRT, hormone replacement therapy *, De ned as dryness, itching, burning or soreness in the vagina, involuntary urination, or vaginal pain in connection with touching and/ or intercourse

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vaginal atrophy, or did not know their cause (Figure 2). Only 4% attributed the symptoms to vaginal atrophy. When asked for the most suitable term to describe dryness, itching, burning or soreness in the vagina or pain during intercourse, 32% chose vaginal dryness, 11% selected vaginal discomfort, 2% opted for poor vaginal health, 2% chose vaginal dysfunction, 28% thought that none of these terms were appropriate, and almost

one-quarter (23%) did not know. Only 2% of women considered vaginal atrophy to be a suitable term. Among the 45% of women specically reporting vaginal discomfort, 83% had experienced vaginal dryness, 42% pain during intercourse, 30% involuntary urination, 27% soreness, 26% itching, 14% burning, and 11% pain when touching the vagina. While 38% of women experiencing vaginal

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Figure 1

Symptoms of menopause experienced by the survey participants (n

3520)

discomfort declared that their symptoms were mild, 62% reported moderate or severe symptoms. Furthermore, over half of women (55%) with vaginal discomfort reported experiencing symptoms for 3 years or longer (Figure 3). In the overall survey population, concerns about menopause-associated vaginal dryness were held by 36% of respondents. Other concerns included involuntary urination (35%), vaginal pain in connection with touching/intercourse (24%), vaginal soreness (22%), vaginal itching (17%), and vaginal burning (15%). Swedish women were the least concerned about most of these symptoms, with the difference being most marked for vaginal dryness (19% of women with concerns in Sweden, compared with 3046% elsewhere). Notably, 63% of all women surveyed did not recognize vaginal discomfort to be a chronic condition requiring treatment of the underlying cause; indeed, 45% did not know whether the condition was acute or chronic. When asked which word or phrase described how a woman might feel about herself when having symptoms of vaginal discomfort, 57% of the survey population selected less sexual,

44% aging, and 39% complicates relationship with partner. Over one-quarter of women also chose dry inside and outside, embarrassed, and less spontaneous. Overall, 75% said that vaginal discomfort would have a negative impact on various aspects of life in general: 65% considered that it would have negative consequences on a womans sex life, 40% thought that it would have negative consequences on marriage or relationships, 36% felt that it would lower quality of life, 31% stated that it would make them feel old, 26% thought that it would have negative consequences on self-esteem, and 13% felt that it would be detrimental to a womans social life. The areas of a womans life thought most likely to be negatively impacted by vaginal discomfort were sexual intimacy (64%), having a loving relationship with a partner (32%), overall quality of life (32%), feeling healthy (21%), and feeling attractive (21%). However, as shown in Figure 4, these perceptions varied somewhat between women from different countries. For instance, while over 70% of women from Great

Figure 2 Conditions thought to cause dryness, itching, burning, or soreness in vagina, or pain during intercourse (n 3520)

Figure 3 Length of time for which symptoms of vaginal discomfort had been experienced (n 1578)

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Vaginal health survey

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Figure 4

Areas of a womans life felt to be negatively impacted by vaginal discomfort

Britain, the United States, Canada and Sweden felt that sexual intimacy would be affected by vaginal discomfort, just 39% of women from Finland agreed. Similarly, only 15% of Finnish women felt that vaginal discomfort would hinder a loving relationship with a partner, compared with 41% of women in Great Britain. Additionally, just 6% of women in Finland felt that vaginal discomfort would prevent a woman from feeling attractive, compared with 34% of British women.

Information sources and advice

Less than half the total survey population (44%) felt that enough information was available about the symptoms and treatment of vaginal discomfort. Again, there was a marked difference in opinion between Finland and other countries: 76% of Finnish women felt enough information to be available, compared with 3742% of women elsewhere. Conversely, respondents from Finland were the least likely to believe that there was not enough information available (10% versus 1941% in the other countries). When asked about the sources of information they had used or would use to understand their symptoms and/or treatment options for vaginal discomfort, women chose the following: their doctor (50%); their gynecologist (46%); menopause websites (31%); medical websites (30%); womens health websites (29%); printed information in their doctors ofce (19%); magazines (15%); friends (14%); family members (5%); and blogs (1%). Women in Great Britain, Canada, Denmark and Norway were more likely to seek information from a doctor (71%, 69%, 67% and 51%, respectively) than women in the United States, Sweden and Finland (49%, 23% and 22%, respectively). Conversely, women in the United

States, Sweden and Finland were more likely to obtain information from a gynecologist (56%, 68% and 76%, respectively) than were women in Great Britain (16%), Canada (34%), Denmark (27%) and Norway (46%). Overall, 53% of survey participants said that they would feel comfortable discussing vaginal discomfort with their doctor. However, 37% would not raise the subject or hesitate to do so. Additionally, less than half (34%) of all participants would speak to their doctor if they developed new symptoms, with Finnish women more likely to do this (56%) than women from the other countries (2436%). In total, 19% of women stated that they would rather try self-treatment before seeing a doctor. Interestingly, 50% of the total survey population claimed that their doctor had not raised the subject of postmenopausal vaginal health; this was true for fewer women in Finland (33%) and Sweden (35%) than in Great Britain (60%), the United States (56%), Canada (59%), Denmark (51%) and Norway (53%). Among survey participants who had experienced vaginal discomfort (n 1578), the majority had sought the assistance of a health-care professional (67%). However, almost one-third (32%) had never seen a health-care professional for treatment. This proportion was highest in Great Britain (46%), lowest in Finland (15%), and similar between the United States, Canada, Sweden, Denmark and Norway (3037%). Gynecologists were most commonly seen by women with vaginal discomfort in Finland (71%) and Sweden (57%), while primary-care physicians were most commonly consulted in Denmark (54%), Great Britain (43%) and Canada (40%). Women in Great Britain were least likely (11%) to visit a gynecologist for this condition. (More information is available in Supplementary Figure 1 to be found online at http://www.informahealthcare.com/cmt/ doi/10.3109/13697137.2012.647840.) Among the women

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Vaginal health survey who had sought the assistance of a health-care professional for symptoms of vaginal discomfort (n 1063), 47% had symptoms for over 6 months before seeing a medical professional, 28% for over 1 year, and 15% for over 2 years.

Nappi and Kokot-Kierepa vaginal discomfort, specic means of treating the underlying cause were less well known. Sixty percent of survey participants were aware of lubricating gels and creams for the effective management of vaginal discomfort, 45% of hormone replacement therapy (HRT) oral tablets and patches, 41% of vaginal hormone creams, 32% of vaginal hormone suppositories, and 23% of vaginal hormone tablets (Figure 5a). Women were more likely to use over-the-counter products for short-term symptom relief than to seek treatment for the

Treatment
While the majority of women were aware of over-the-counter products to give temporary relief from the symptoms of

(a)

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(b)

Figure 5 (a) Effective treatments for vaginal discomfort of which women were aware (n discomfort

3520); (b) treatments used by women with vaginal

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Vaginal health survey underlying cause of vaginal discomfort (Figure 5b). Among the 1578 respondents who had experienced vaginal discomfort since they stopped menstruating, almost half (49%) had tried lubricating gels and creams, 22% HRT oral tablets or patches, 17% vaginal suppositories, 13% vaginal hormone creams, 13% mineral/vitamin supplements, 12% vaginal hormone tablets, and just 1% had used a vaginal hormone ring. A further 22% had tried none of these options. Women in Norway and Denmark were less likely to have used HRT oral tablets and patches than in other countries, but were more likely to have tried vaginal hormone suppositories. Similarly, women in Finland and Sweden were much more likely to have used vaginal hormone tablets than those elsewhere (Figure 5b). Fifty-three percent of the overall survey population said that they associated oral HRT tablets and patches with an increased risk of breast cancer, and 46% associated such treatment with an increased risk of developing a stroke or blood clot. Positive perceived associations included slower aging (19%), feeling more energetic (18%), and increased interest in sex (18%). Overall, 62% of women reported having negative associations with HRT, just 33% held positive associations, and 28% did not know what to associate with HRT. While 36% would have considered taking HRT oral tablets and/or patches, 21% remained undecided. Almost half (46%) the surveyed women did not know what perceptions to associate with local estrogen therapy, and the proportions holding negative and positive associations were 33% and 23%, respectively. More women in Great Britain, the United States and Canada were unaware of the effects of local estrogen therapy (60%, 55% and 52%, respectively) than in Sweden (42%), Denmark (37%), Finland (36%) and Norway (43%). Negative associations with such treatment, however, were held by more women in Denmark (43%) than in the other countries (2239%), while Finnish women were more likely to associate local estrogen therapy with positive effects (35% versus 1826% in other countries). In total, 27% of survey participants associated local estrogen therapy with an increased risk of developing breast cancer, and 24% reported concerns relating to increased risk of developing a blood clot or stroke. Positive associations included increased interest in sex (15%), slower aging (12%), and feeling more energetic (10%). While 30% of women said that they would not consider taking local estrogen therapy if they knew it to be effective and capable of maintaining normal hormone levels and 20% were undecided, 49% said that they would be willing to try this, with vaginal tablets being the form preferred by most women (27%). The proportions of women who stated a preference for vaginal tablets were 37% (Great Britain), 21% (United States), 25% (Canada), 30% (Sweden), 18% (Denmark), 38% (Finland) and 22% (Norway). Most women (61%) did not expect their vagina to be the same as during their youth, but would welcome greater comfort, while 78% desired the freedom to be the women they wanted to be, regardless of age.

Nappi and Kokot-Kierepa

DISCUSSION
Our survey demonstrates that postmenopausal women have a poor understanding of vaginal atrophy and its symptoms, and, as they are at the time in their lives when they are most likely to experience the impact of this condition, the lack of awareness is of great concern. For instance, although 45% of our postmenopausal survey participants had experienced symptoms of vaginal atrophy, 96% of the total survey population would attribute such symptoms to other conditions (e.g. menopause, candidiasis or bladder infection) or did not know their cause. Additionally, the majority of respondents (63%) did not recognize vaginal atrophy to be a chronic condition that requires ongoing treatment of the underlying cause. Most of the women (64%) considered that sexual intimacy was the area of life most likely to be affected by the symptoms of vaginal atrophy, but it was also felt that other aspects would be negatively impacted by the condition. Overall, the rates of vaginal symptoms experienced by our survey population did not vary greatly between different countries. This suggests that the prevalence of vaginal atrophy itself may not be dependent on sociocultural factors and may instead be a universally experienced biological consequence of estrogen deprivation. In contrast, womens access to a gynecologist did vary between countries: for instance, 73% of women in Great Britain did not have access to a gynecologist, while this gure was just 15% for Finnish women. Differences in level of access to gynecologists highlight the differences in health-care systems that function across the countries included in the survey, possibly indicating differences in the level of vaginal health care available. We also found that womens views and perceptions of vaginal atrophy and its symptoms varied according to country. It is possible that these varied opinions also arise from country-specic differences in health-care systems and perhaps from the level of openness about vaginal atrophy in the media and society in general. The majority of Finnish women (76%), for example, felt that there was enough information available about symptoms and treatment, compared with just 3742% in the other countries. This nding concurs with results from the International Vagina Dialogue Survey, which found that, of the 13 countries involved, women from Finland were least likely to agree that vaginal health did not receive the attention it deserves15. In the current survey, more women in Finland than in any other country claimed that their doctor had initiated discussions about postmenopausal vaginal health; additionally, when compared with their counterparts of other nationalities, Finnish women were also much more likely to seek assistance from a health-care professional and to speak to their doctor if they developed new vaginal symptoms. Interestingly, Finnish respondents were also the least likely to believe that vaginal discomfort would have detrimental effects on sexual intimacy, loving relationships with partners, and a womans ability to feel attractive (Figure 4). This suggestion that vaginal atrophy is perceived in a less negative light in Finland might be attributable to a greater amount of

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Vaginal health survey information available to women in this country and to a greater level of openness to discussing vaginal problems; it might also be inuenced by attitudes towards sexuality. While full exploration of this argument is beyond the scope of this paper, it does raise interesting questions about the inuence of societal values, media coverage and health-care education on womens perceptions of, response to, and attitudes towards vaginal atrophy and its impact on sexual functioning and everyday life. These country-specic differences aside, however, almost one-third (32%) of all respondents who had experienced symptoms of vaginal atrophy had never sought assistance from a health-care professional; indeed, only 50% of respondents said that they would consult their doctor to obtain information on symptoms or treatment. Almost half (47%) of women with symptoms of vaginal atrophy waited for more than 6 months before consulting a medical professional, and over one-quarter (28%) waited for more than 1 year. As with any survey, there is a possibility of bias in the individuals electing to participate, but other reports in the literature have also found that women are often reluctant to seek medical assistance1,2,16,17, with some authors suggesting that women only present to a health-care professional when the vulva is excoriated from chronic scratching16. As already mentioned, in our previous international survey of womens views and perceptions of the menopause, 39% of the postmenopausal cohort had experienced vaginal atrophy; however, around 70% had not discussed it with a doctor or gynecologist, and 77% of the interviewees believed that women were uncomfortable discussing the condition with a medical professional14. The taboo nature of vaginal problems undoubtedly plays a role in the reluctance of women to seek medical care for their symptoms, with embarrassment and/or cultural values1,2 enforcing the perception that this subject is out of bounds. In addition, women perhaps nd it easier to discuss symptoms such as hot ushes and night sweats with their doctors; not only are these symptoms less intimate in nature than vaginal and sexual problems, but they are also more obvious and expected consequences of menopausal estrogen depletion and might overshadow the less well-known and more infrequently discussed problems associated with vaginal atrophy. However, we believe that these factors do not fully account for the observed propensity of women to suffer in silence. Instead, it is likely that a lack of understanding regarding the underlying pathophysiology of vaginal atrophy, its chronic nature, and its association with reduced estrogen levels and not just with the menopausal transition is responsible for many women deciding to live with their symptoms rather than seek treatment. Indeed, many women believe that vaginal symptoms are an inevitable, irreversible, and essentially untreatable consequence of aging and/or the menopause1,2. Given this lack of understanding and the subsequent reluctance among women to consult a medical professional about their symptoms, it is perhaps unsurprising that the overall survey population had a poor awareness of the treatments

Nappi and Kokot-Kierepa available for vaginal atrophy. Perhaps because they failed to appreciate the long-term effects of estrogen deprivation on the female urogenital tissues, women appeared more likely to use over-the-counter lubricants and moisturizers (49%) for the temporary relief of vaginal atrophy symptoms than to seek treatments that addressed the underlying condition. Most women in our survey were wary of systemic HRT, with 62% of the overall population holding negative perceptions of such treatment and 43% stating that they would not be willing to use it, even if they knew it was effective. Overall, women seemed to be much less aware of the availability and effects of local estrogen therapy, with almost half (46%) of all respondents reporting that they knew very little about its expected outcomes and potential side-effects. These results support those of our previous survey, in which 42% of women were unaware of the availability of local estrogen treatment14. In the current survey, women from Great Britain, the United States and Canada were particularly likely to be unaware of local estrogen therapy: 60%, 55% and 52% of women from these countries, respectively, reported a lack of knowledge regarding the effects or benets of local estrogen treatment, compared with 3643% of their Scandinavian counterparts. Overall, however, a similar proportion of women (49%) expressed a willingness to try local estrogen therapy, and just 33% held negative perceptions of such treatment. Thus, a substantial number of women with symptoms of vaginal atrophy are neither aware of, nor are receiving, effective therapy. Differences between the proportions of women using such therapies and those who claimed they would be willing to try them may reect differences in levels of awareness of therapeutic benets. While vaginal atrophy remains a persistent consequence of estrogen depletion16,18, the distressing symptoms that result from vaginal atrophy can be treated2. The vaginal response to estrogen treatment is rapid and sustained1 and treatment with local estrogen is a relatively simple therapeutic strategy that can transform a womans quality of life1,13. Women should be made aware that there are a number of different options available for local estrogen therapy (e.g. tablets, creams, suppositories, rings), and the best choice for each individual patient is largely a matter of personal preference. Whichever option is chosen, low doses are recommended, and most women would appear to feel more comfortable taking low-dose treatment. These observations support the view that ultra-low doses might be the preferred option for postmenopausal women treated with local vaginal estrogen therapy1921. Furthermore, local vaginal treatments may represent a much more attractive option to most women than systemic HRT products. As long as women remain unaware of the availability and effectiveness of local estrogen therapies, they will continue to self-treat with overthe-counter products to achieve a quick-x solution for their symptoms. Therefore, there is an urgent need to educate women about the underlying pathology of vaginal atrophy and the availability of intravaginal estrogens for its simple, effective resolution1. Women should also be given the opportunity to discuss sexual problems arising from vaginal atrophy,

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Vaginal health survey as early recognition of postmenopausal women distressed by sexual dysfunction is a crucial step towards effective therapeutic management11. Supportive guidance and factual information about changes in sexual functioning have been shown to help in the management of women with vaginal atrophy16. Medical practitioners should proactively raise the topic of vaginal health, help patients to understand that vaginal atrophy is a chronic condition, and discuss treatment options as appropriate, so that more women can receive timely and effective therapy.

Nappi and Kokot-Kierepa Conict of interest R. E. Nappi is a consultant to, and researcher for, Novo Nordisk. M. Kokot-Kierepa is an employee of Novo Nordisk FemCare AG, Switzerland. Source of funding The VIVA survey was commissioned by Novo Nordisk FemCare AG, Switzerland. The results have been presented at the 13th World Congress on Menopause (June 2011). Assistance with writing this manuscript was provided by Monica Nicosia and Andy Lockley of Bioscript Stirling Ltd, UK, and funded by Novo Nordisk FemCare AG, Switzerland.

References
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Supplementary material available online Supplementary Table and Figure to be found online at http:// www.informahealthcare.com/cmt/doi/10.3109/13697137. 2012.647840

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