Gladys is 74 and comes to see you because she is sore “down below.” She finds her knickers are irritating her, and sometimes she notices a pink discharge. She has been a widow for 5 years and has not been sexually active for a decade. Her “change of life” was uneventful and she has never taken hormone replacement therapy. She has also noticed that she doesn't get much warning when she needs to pass urine and this is making her life very difficult. Introduction The term vulvo-vaginal atrophy (VVA) defines the anatomic and physiological changes in the vulvo-vaginal tissues which are directly related to the reduced circulating estrogen levels associated with menopause and to aging. Atrophic vaginitis connotes a state of inflammation or infection that may be present in some women with VVA. Vulvo-vaginal atrophy or atrophic vaginitis is a medical challenge because it is under-reported by women, under-recognized by health-care providers (HCPs) and, therefore, under-treated. The most common symptoms associated with VVA are dryness, itching, irritation, burning and dyspareunia that may negatively influence well-being and partnership. Even other urinary symptoms are eventually associated with VVA, such as increased frequency, urgency, dysuria and recurrent urinary tract infections (rUTIs), as well as urinary incontinence resulting mainly from pelvic floor relaxation. According to recent surveys, about 50% of postmenopausal women experience vaginal discomfort attributable to VVA. Longitudinal data showed that the prevalence of vaginal dryness, the most common symptoms associated with VVA, ranged from about 3% at premenopause to 47% at 3 years postmenopause. Epidemiologic findings are influenced by a range of factors, including age, time since menopause, frequency of sexual activity, general health, partner's availability and socio-cultural background. In addition, most of the data rely on self-reported symptoms and the severity of symptoms (from mild to severe) is rather subjective. Indeed, objective signs of VVA may be present but women may not report symptoms because they are self-treating, feel the symptoms are not important enough, abstain from sexual activity because of no partner/a partner with health/sexual problems or are embarrassed to discuss such an intimate topic.
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