The main finding of this survey is that the sample of women analyzed have poor knowledge about GSM, particularly about treatment options. In addition, there is also a clear lack of communication between women and their gynecologist in relation to the issue of sexuality. To date, this is the largest sample of women to have been surveyed about their beliefs and knowledge regarding GSM, its treatments, and associated sexuality issues in Spain. In addition, during the extension phase, we have verified that adherence to GSM treatments has been remarkably poor during the coronavirus confinement period. To our knowledge, this is the first study to assess compliance with treatment for GSM during the coronavirus pandemic.
Several studies have analyzed the prevalence and impact of vulvo-vaginal atrophy (VVA) symptoms experienced during menopause (9–12) The most common symptom among all of these is vaginal dryness, with the European EVES study reporting an estimated prevalence of up to 90%. Dyspareunia is less prevalent (44–72%) but is the most bothersome symptom (9, 10, 12). Sexuality is the most affected area, as indicated by the VIVA (65%) (11), and the American REVIVE (59%) surveys (9). In the CLOSER study, the reduction of sexual satisfaction and dyspareunia are causes of significant sexual dysfunction (13). However, in some of these studies, vaginal atrophy was not recognized as a medical condition by several women, who felt that their concerns had been dismissed as a normal part of aging (9, 10, 14).
When asked about the conditions or symptoms associated with menopause, most of the women in our survey identified vaginal dryness (74.3%); whilst other conditions such as decreased desire or sexual dysfunction were less recognized (44.8% and 29% respectively). The attitudes of the women towards their symptoms are highly variable and may depend on sociocultural and even personality factors (8, 9, 13). For instance, according to the REVIVE surveys (9, 10), women in Europe appear to be more aware of the fact that vaginal dryness and dyspareunia are menopausal symptoms (53%) than women in the USA (38%).
Another factor that could be associated with the perception of VVA symptoms is communication with the clinicians and the attitude of women in relation to raising the issue of GSM, that is, whether they discuss the symptoms with their health care practitioner during their gynecological appointments. When we specifically asked about sexuality in menopause, only a limited number of women believed that menopause does not affect sexuality (13%). The majority (65%) thought that menopause decreased sexual desire and almost half (34.9%) recognized the symptom of pain during sexual intercourse. According to the AGATA study, 78.7% of 913 patients with VVA had never been questioned by a health care practitioner (15).
In accordance with our findings, the Women’s EMPOWER survey, an internet-based survey of US women with VVA symptoms (4), reported that most women were aware of over-the-counter treatments (vaginal lubricants or moisturizers) but knew rather less about options such as local estrogen treatments. Other surveys evaluated the knowledge, behavior, and attitudes associated with GSM; the authors valued treatments women receive, their satisfaction and concerns, but the treatment options that women are aware of are not discussed in depth (9, 10, 15, 16). This is an important aspect to consider if patients are to choose the most appropriate treatment according to their preferences. It is clear that as gynecologists we must improve the information that we provide to our patients in this regard.
The issue of communication with the clinician in relation to sexuality is particularly interesting. Most of the women in our sample (66.4%) reported that they did not discuss the topic of sexuality with their gynecologist, the reason for which, according to the majority of women (57.1%), was that their clinician had never asked them. In accord with this finding, other studies have shown that women expect their gynecologist to begin the conversation in this regard, and that these women have a strong desire to obtain accurate medical information about VVA (4). A study was conducted in Spain to evaluate whether actively addressing sexuality in a gynecological consultation with postmenopausal patients improves the diagnosis of sexual problems (18). A total of 256 postmenopausal women participated in the study. Of these, 12.1% reported a sexual problem during the first 5 minutes of the interview. The prevalence of patients with a sexual problem increased by 35.9% (from 12.1–48.0%) when they were asked about sexuality after 5 min (p < 0.0001). These findings suggest that gynecologists should reflect on this issue and consider asking all menopausal women about sexuality.
The clinical efficacy of a treatment over time varies depending on persistence and compliance. Lack of adherence to treatment in chronic diseases is a major problem worldwide (19). In GSM, both adherence and persistence are low. Among women with GSM who participated in the REVIVE study in Spain, 40% reported having discontinued treatment for GSM (20). However, our data are even more discouraging. To date, no other study has assessed adherence to GSM treatments during the current coronavirus pandemic. These novel findings should encourage clinicians to reflect on the importance of motivating their patients and emphasizing the benefits of good treatment compliance to avoid unfavorable clinical and economic consequences.
One limitation of our study was the possible selection bias. To minimize this source of bias, the size of the sample was increased and participation in the survey was offered to all women regardless of the reason for their medical visit. Nonetheless, we must assume that the obtained conclusions cannot be extrapolated to the general population and are instead limited to the sample included in the study. Nonetheless, this work might be considered a useful exploratory study that could form the basis for future investigations in the general population. Another possible limitation of our study is related to the choice of questionnaire. There are currently no questionnaires in Spanish that have been sufficiently recognized and validated as an instrument for measuring women's knowledge of menopause. Finally, conducting the Morisky-Green-Levine questionnaire by telephone (which was deemed necessary due to the confinement situation) could also be viewed as a limitation, since the obtained data may be rather different to those that would have been yielded by a self-administered test.