Vasomotor and Sexual Symptoms in Women Aged 60 to 65 Years
Vasomotor and Sexual Symptoms in Women Aged 60 to 65 Years
Consistent with previous reports, the use of systemic HT by study participants in this population-based cross-sectional study was low such that nearly one third of postmenopausal women younger than 55 years had untreated moderate to severe VMS. Our study also shows that the proportion of postmenopausal women presently using HT is not lower in older women, despite current clinical guidelines recommending that HT ideally be limited to 3 to 5 years of use and not be initiated in women more than 10 years since menopause or in women older than 60 years. That nearly 10% of women aged 60 to 65 years were current HT users highlights a "disconnect" between some guideline recommendations and the reality of clinical practice, with clinicians continuing to prescribe HT for older women with persistent symptoms. Moreover, the use of nonhormonal prescription therapies with proven efficacy, such as selective serotonin reuptake inhibitors or gabapentin, was strikingly low, suggesting that menopause has gone "off the radar" as an important health issue and remains undertreated despite its far-reaching effects on quality of life and its impact on work function.
Furthermore, our data show that menopausal symptoms, particularly vasomotor and sexual symptoms, remain highly prevalent in women aged 60 to 65 years who are not taking HT. Almost half of women aged 60 to 65 years reported any VMS, and nearly two thirds reported sexual symptoms.
Postmenopausal women aged 60 to 65 years were the greatest users of vaginal estrogen (7.8%), yet the prevalence of sexual symptoms was high across all age groups. Taken together with evidence that dyspareunia increases from early menopause to late menopause, our findings indicate that vulvovaginal atrophy remains undertreated across all postmenopausal age groups.
Few studies have described the prevalence of moderate to severe VMS as opposed to the prevalence of any VMS. Past studies that reported menopausal symptoms have been limited by the use of nonvalidated measures, the use of VMS frequency rather than symptom bother, or the use of fourpoint scales (which are less precise than the seven-point scale used in the MENQOL). Although the MENQOL is validated to report domain scores, separating out women who reported that they were moderately to severely bothered by their symptoms provides a clinical context. Sufficient bother by symptoms, rather than the mere presence of any VMS, motivates women to seek treatment. This approach also allowed us to examine factors associated with symptoms that are likely to be of clinical importance.
In our study, smoking cigarettes was associated with any VMS and moderate to severe VMS, whereas women with higher level of education were less likely to report moderate to severe VMS, consistent with findings from other studies.
Obesity has been positively associated with any VMS in numerous studies, but studies examining the association between moderate to severe VMS and BMI have produced conflicting findings. Having a sample size that is sufficient to identify women with class III obesity (BMI ≥40 kg/m) enabled us to demonstrate that class III obesity was associated with any VMS but that only a BMI of 25 to 29.9 kg/m was associated with moderate to severe VMS.
Strengths of our study include the use of a validated measure of menopausal symptoms and the recruitment of a large community-based sample with age distribution mimicking that of the adult Australian female population aged 40 to 65 years. A potential weakness was the requirement for women to be able to complete an English-language questionnaire. It is improbable that this language requirement affected the representativeness of the sample, as English literacy in Australian women exceeds 96%. Recruitment was performed randomly based on the electoral roll. That 42% of the women invited to participate in the study declined indicates that selection pressures were operative. Women may have been uninterested or unwilling to divulge sensitive personal information when advised that the study included questions about sexual health. Nonetheless, comparison with 2011 Australian census data confirms that our sample is nationally representative of women aged 40 to 65 years. Population characteristics similar to our sample include obesity (31.1%), smoking (16.6%), any alcohol use (75.5%), being partnered (70%),and being white (92%). In addition, unlike earlier studies, we did not exclude from our sample women who reported hysterectomy and use of systemic hormones.
Other potential limitations were inability to compare the demographics of respondents and nonrespondents because of privacy guidelines and not having an estimate of the number of years since menopause. We deliberately did not ask women about the number of years since menopause because menopause could have been decades earlier for some women, some had been hysterectomized, and others were using systemic hormonal contraception. We did not include in our analysis physical activity that may also affect VMS. Although height and weight were self-reported, substantial agreement between BMI calculated from self-report and physicians' measures has been demonstrated.
Discussion
Consistent with previous reports, the use of systemic HT by study participants in this population-based cross-sectional study was low such that nearly one third of postmenopausal women younger than 55 years had untreated moderate to severe VMS. Our study also shows that the proportion of postmenopausal women presently using HT is not lower in older women, despite current clinical guidelines recommending that HT ideally be limited to 3 to 5 years of use and not be initiated in women more than 10 years since menopause or in women older than 60 years. That nearly 10% of women aged 60 to 65 years were current HT users highlights a "disconnect" between some guideline recommendations and the reality of clinical practice, with clinicians continuing to prescribe HT for older women with persistent symptoms. Moreover, the use of nonhormonal prescription therapies with proven efficacy, such as selective serotonin reuptake inhibitors or gabapentin, was strikingly low, suggesting that menopause has gone "off the radar" as an important health issue and remains undertreated despite its far-reaching effects on quality of life and its impact on work function.
Furthermore, our data show that menopausal symptoms, particularly vasomotor and sexual symptoms, remain highly prevalent in women aged 60 to 65 years who are not taking HT. Almost half of women aged 60 to 65 years reported any VMS, and nearly two thirds reported sexual symptoms.
Postmenopausal women aged 60 to 65 years were the greatest users of vaginal estrogen (7.8%), yet the prevalence of sexual symptoms was high across all age groups. Taken together with evidence that dyspareunia increases from early menopause to late menopause, our findings indicate that vulvovaginal atrophy remains undertreated across all postmenopausal age groups.
Few studies have described the prevalence of moderate to severe VMS as opposed to the prevalence of any VMS. Past studies that reported menopausal symptoms have been limited by the use of nonvalidated measures, the use of VMS frequency rather than symptom bother, or the use of fourpoint scales (which are less precise than the seven-point scale used in the MENQOL). Although the MENQOL is validated to report domain scores, separating out women who reported that they were moderately to severely bothered by their symptoms provides a clinical context. Sufficient bother by symptoms, rather than the mere presence of any VMS, motivates women to seek treatment. This approach also allowed us to examine factors associated with symptoms that are likely to be of clinical importance.
In our study, smoking cigarettes was associated with any VMS and moderate to severe VMS, whereas women with higher level of education were less likely to report moderate to severe VMS, consistent with findings from other studies.
Obesity has been positively associated with any VMS in numerous studies, but studies examining the association between moderate to severe VMS and BMI have produced conflicting findings. Having a sample size that is sufficient to identify women with class III obesity (BMI ≥40 kg/m) enabled us to demonstrate that class III obesity was associated with any VMS but that only a BMI of 25 to 29.9 kg/m was associated with moderate to severe VMS.
Strengths of our study include the use of a validated measure of menopausal symptoms and the recruitment of a large community-based sample with age distribution mimicking that of the adult Australian female population aged 40 to 65 years. A potential weakness was the requirement for women to be able to complete an English-language questionnaire. It is improbable that this language requirement affected the representativeness of the sample, as English literacy in Australian women exceeds 96%. Recruitment was performed randomly based on the electoral roll. That 42% of the women invited to participate in the study declined indicates that selection pressures were operative. Women may have been uninterested or unwilling to divulge sensitive personal information when advised that the study included questions about sexual health. Nonetheless, comparison with 2011 Australian census data confirms that our sample is nationally representative of women aged 40 to 65 years. Population characteristics similar to our sample include obesity (31.1%), smoking (16.6%), any alcohol use (75.5%), being partnered (70%),and being white (92%). In addition, unlike earlier studies, we did not exclude from our sample women who reported hysterectomy and use of systemic hormones.
Other potential limitations were inability to compare the demographics of respondents and nonrespondents because of privacy guidelines and not having an estimate of the number of years since menopause. We deliberately did not ask women about the number of years since menopause because menopause could have been decades earlier for some women, some had been hysterectomized, and others were using systemic hormonal contraception. We did not include in our analysis physical activity that may also affect VMS. Although height and weight were self-reported, substantial agreement between BMI calculated from self-report and physicians' measures has been demonstrated.