Urogenital Atrophy – a silent epidemic 1Paula Briggs1,2, Gayathri Delanerolle3, Rachel Burton2, Jian Qing Shi4,5, Haitham Hamoda6, Dharani K. Hapangama1,2Affiliations:1Liverpool Women’s Hospital NHS Foundation Trust, Liverpool, UK2Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK3University of Oxford, UK4The Alan Turing Institute, UK5Southern University of Science and Technology, China6King’s College Hospital, London UK, Chairman of the British Menopause SocietyCorresponding author: Paula Briggs, Email: [email protected] atrophy describes the multiple changes in urogenital tissues, most commonly due to hypoestrogenism associated with the menopause and ageing. It results in an alteration of the appearance and function of the vulva, vagina, urethra and bladder. The mucosal epithelium becomes thinner and is prone to inflammation and trauma and the collagen fibres in the dermal layer hyalinise and fuse, which in association with fragmentation of elastin fibres, reduces tissue elasticity. These changes can collectively result in pain and bleeding, most notably in association with sexual activity. Most menopausal women are affected by these changes in tissue quality to some degree, and therefore there is a need for better communication and education for women, their partners and their health care providers, to reduce any potential negative effect on sexual function and quality of life2,3. Similarly, to optimise clinical outcomes and maximise patient benefit, fit for purpose diagnostic standards should be developed4.There are two key research surveys that demonstrate valuable information that could aid in advancing current clinical practices, namely The European REVIVE Survey5 and VIVA-LATAM6. The REVIVE survey was conducted in four European countries including Germany, Spain, Italy and the UK (3768 postmenopausal women between the ages of 45-75 participated), while the VIVA-LATAM survey was conducted in Latin American countries including Argentina, Brazil, Chile, Colombia and Mexico (2509 women aged 55-65 participated). Both surveys were designed to establish awareness of the effect of lack of estrogen on urogenital tissue quality. Symptoms were frequent and treatment, particularly local hormone therapy was more likely in women who have had a discussion with a health care professional (HCP). Women wanted advice, but it was offered proactively only in a small proportion of cases. The conclusion of both surveys confirms that urogenital atrophy is an under-recognised, under-diagnosed and under-treated chronic condition and they highlight that there is a need for a public awareness and education campaign. Women surveyed in REVIVE felt most concerned about loss of sexual intimacy and youth. This was echoed by the findings in another survey CLOSER7, a quantitative internet survey, including 8200 individuals from nine different countries, with participation of 500 men and 500 women from the UK. The results of this study highlighted the adverse emotional and physical impact of urogenital atrophy on postmenopausal women and their partners, with vaginal dryness and dyspareunia associated with loss of arousal and desire. The conclusion focussed on the potential benefit of more open communication with affected women, to improve access to treatment and for healthcare providers to initiate the discussion. Another study, the AGATA8 study, involved 913 Italian women and following clinical assessment in women with symptoms, prevalence of urogenital atrophy was estimated to range between 65-84%. Authors concluded that urogenital atrophy is a common condition, which is underdiagnosed and therefore undertreated. However, a follow up study by the same group, undertaken in a subset of already diagnosed women, demonstrated lack of consistency in the management of the condition from a clinician perspective and lack of compliance from a patient’s perspective9. This further reinforces the need for education of both the clinicians and women and the requirement of support including a validated objective method of assessment to assist in diagnosis.The impact of urogenital atrophy on sexual function is determined by a number of factors including a reduction in blood flow to the vulva & vagina with a decrease in vaginal secretions and an adverse effect on neuronal function both of which can alter sensation and sexual pleasure. Some authors have reported nerve density and size to be influenced by dehydroepiandrosterone (DHEA) and androgens, thus explaining the beneficial effects demonstrated with such therapy on postmenopausal sexual function. Sexual intimacy remains an important aspect of relationships for older women and enquiry about symptoms of urogenital atrophy should be routinely included in all consultations about menopause. This would help to remove a major barrier restricting access to treatment for affected women, who find the subject difficult to broach. Other hurdles to accessing treatment include limited research, the cost of treatment and patient fear of treatment options10.Reported prevalence rates for urogenital atrophy vary even more widely than the figure quoted for the AGATA study, with 10% - 84%7 of women going through menopause affected by urogenital atrophy associated symptoms to some degree. Many women accept symptoms as a normal part of aging and thus, may not seek medical help20. It is difficult to predict which women will develop urogenital atrophy, with some women unaffected possibly due to genetically determined tissue quality and also possibly due to production of DHEA from the adrenal glands. However, in general the number of women affected increases year on year from menopause onwards due to the progressive effect of estrogen deficiency.The Stages of Reproductive Ageing Workshop (STRAW)11suggested that symptoms of urogenital atrophy are likely to present between three and six years after last menstruation, although this can occur at an earlier time. Some affected women may not associate their symptoms with the menopause, if there is a long period between the cessation of menstruation and the appearance of symptoms. For this reason, it is particularly important that clinicians providing health care to menopausal women proactively ask about common symptoms of urogenital atrophy including vaginal dryness, itching, burning, pain during sexual intercourse and urinary problems.