Experts' view on the role of oestrogens in combined oral contraceptives: emphasis on oestetrol (E4).

Introduction: The evolution of contraception has been crucial for public health and reproductive well-being. Over the past 60 years, combined oral contraceptives (COCs) have remained an important part of the contraceptive landscape worldwide; continued development has worked toward maintaining efficacy and improving safety. Methods: Seven global experts convened to discuss the clinical relevance of the oestrogen in COCs, focusing on the impact of the new oestrogen, oestetrol (E4). Participants then commented through an online forum on the summary content and other participants' feedback. We prepared this report to describe the experts' views, their follow-up from the open forum and the evidence supporting their views. Results: Ethinylestradiol (EE) and oestradiol (E2) affect receptors similarly whereas E4 has differential effects, especially in the liver and breast. Adequate oestrogen doses in COCs ensure regular bleeding and user acceptability. EE and E4 have longer half-lives than E2; accordingly, COCs with EE and E4 offer more predictable bleeding than those with E2. Oestrogen type and progestin influence VTE risk; E2 poses a lower risk than EE; although promising, E4/DRSP VTE risk is lacking population-based data. COCs alleviate menstrual symptoms, impact mental health, cognition, libido, skin, and bone health. Conclusion: Oestrogens play an important role in the contraceptive efficacy, bleeding patterns, and overall tolerability/safety of COCs. Recent studies exploring E4 combined with DRSP show promising results compared to traditional formulations, but more definitive conclusions await further research.

Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study.

OBJECTIVES: To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy. METHODS: This prospective study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution. RESULTS: During the study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi. CONCLUSION: EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Relation between adenomyosis and elastographic characteristics of the cervix.

STUDY QUESTION: Is there a possible etiologic link between cervical stiffness and adenomyosis? SUMMARY ANSWER: Women with adenomyosis have a stiffer internal cervical os than those without adenomyosis. WHAT IS KNOWN ALREADY: An increased myometrial contractility during menses, leading to breaches in the endometrial basal lamina and subsequent infiltration of endometrial cells into the myometrium, has been proposed as a possible pathogenic mechanism for adenomyosis. Intense menstrual pain has already been shown to be associated with an increased stiffness, at elastography, of the internal cervical os. STUDY DESIGN, SIZE, DURATION: A cross-sectional study on 275 women was performed between 1 February and 31 July 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Among the participants, 103 were and 172 women were not affected by adenomyosis as evaluated by ultrasonography. General and clinical characteristics of the patients were collected. Strain elastography was used to document tissue stiffness at different regions of interest of the cervix, i.e. the internal cervical os, the middle cervical canal, the anterior and the posterior cervical compartment. Tissue stiffness was expressed as a colour score from 0.1 = blue/violet (high stiffness) to 3.0 = red (low stiffness). Simple and multiple logistic regression analyses were used to evaluate the relation between the presence of adenomyosis, as the dependent variable, and independent factors. MAIN RESULTS AND THE ROLE OF CHANCE: Women with adenomyosis had a higher prevalence (P = 0.0001) and intensity (P = 0.0001) of pain during menses, between menses and at intercourse compared to control. The internal cervical os colour score was lower (higher stiffness) in women with adenomyosis (0.55 ± 0.29 versus 0.67 ± 0.26; P = 0.001) and the middle cervical canal/internal cervical os colour score ratio was greater (3.32 ± 4.36 versus 2.59 ± 4.99; P = 0.008), compared to controls. Upon logistic regression modelling (R2 = 0.077), the internal cervical os stiffness was an independent factor related to adenomyosis (odds ratio (OR) 0.220, 95% CI 0.077, 0.627; P = 0.005) along with age (P = 0.005) and the use of gonadal steroid therapies (P = 0.002). We obtained the same results using a different logistic regression model (R2 = 0.069), by substituting the internal cervical os stiffness with the ratio of the middle cervical canal/internal cervical os stiffness (OR 1.157, 95% CI 1.024, 1.309; P = 0.019). LIMITATIONS, REASONS FOR CAUTION: Women did not undergo surgery therefore we have no histological confirmation of the adenomyosis diagnosis. Strain elastography is a semiquantitative analysis and can be conditioned by the force applied by the operator during the analysis. The data were obtained mainly in White women in a single centre. WIDER IMPLICATIONS OF THE FINDINGS: To the best of our knowledge, this is the first study indicating that women with adenomyosis have an increased stiffness of the internal cervical os. The results indicate that a stiff internal cervical os, as determined by elastography, is a possible contributor to the development of adenomyosis. These findings may have clinical significance and should prompt further investigation. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: N/A.

Vaginal oxygen plus hyaluronic acid on genito-urinary symptoms of breast cancer survivors.

OBJECTIVES: This study aimed to evaluate the efficacy of vaginal oxygen and hyaluronic acid on genito-urinary symptoms of breast cancer survivors. METHODS: Patients were enrolled at the Menopause Outpatient Clinic of a university hospital. Breast cancer patients in a stable relationship, suffering from vaginal atrophy (VA) consequent to hypoestrogenism, were included. Natural oxygen was introduced into the vagina for 15 min, coupled in the last 5 min with a 2% solution of hyaluronic acid. Treatment was repeated five times, every 15 days. RESULTS: Out of the 40 breast cancer patients enrolled, 65% had no sexual intercourse due to pain. During treatment, the Vaginal Health Index Score gradually improved from 9.5 ± 2.2 to 16.8 ± 2.8 (p < 0.001), the visual analog scale score for dyspareunia decreased from 8.9 ± 1.3 to 3.4 ± 2.1 (p < 0.001) and the Female Sexual Function Index increased from 8.6 ± 6.3 to 15.2 ± 8.1 (p < 0.001). At the end of treatment, only 15% women (p = 0.001 vs. pretreatment) had no intercourse due to pain. Benefits remained 30 days after last treatment. CONCLUSION: Vaginal oxygenation coupled with hyaluronic acid every 15 days improves VA, sexuality and urinary symptoms of breast cancer patients. Beside data confirmation, additional studies are needed to determine the best interval between treatments, the optimal length of treatment and the long-term duration of the benefits.

Symptomatic enhanced myometrial vascularity after medically managed early miscarriage or abortion. A case series.

This case series evaluates clinical outcomes and sonographic features of symptomatic enhanced myometrial vascularity developed after either first trimester medical abortion or miscarriage management. All cases were followed until spontaneous resolution. Ultrasonography alongside persistent low serum ß-HCG supports enhanced myometrial vascularity diagnosis and expectant management is a feasible approach.

Relation between blood pressure and genito-urinary symptoms in the years across the menopausal age.

OBJECTIVES: This study aimed to evaluate the relation between blood pressure (BP) or heart rate and genito-urinary symptoms in 504 women across the menopausal age (40-55 years old). METHODS: In this multicenter, cross-sectional study, data of office systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate were related to the presence of vaginal dryness, dyspareunia, vaginal atrophy (VA), recurrent urinary infection (RUI), hot flushes (HF) or menopausal status. RESULTS: Vaginal dryness (coefficient of linear regression ß = 5.45, 95% confidence interval [CI] 2.01-8.89; p = 0.0001), VA (ß = 3.79, 95% CI 0.84-6.74; p = 0.002) and RUI (ß = 3.91, 95% CI 0.72-7.09; p = 0.0163) were independently related to SBP. Vaginal dryness (ß = 3.28, 95% CI 0.95-5.61; p = 0.0058), and HF (ß = 2.29, 95% CI 0.29-4.28; p = 0.025) were independently related to DBP. Dyspareunia (ß = 2.11, 95% CI 0.50-3.72; p = 0.010) was independently related to heart rate. Hypertension was present in 17% of women. When corrected for body mass index (BMI), risk factors for hypertension were VA (OR 2.50, 95% CI 1.43-4.40; p = 0.0014), RUI (OR 1.94 95% CI 1.06-3.52; p = 0.0302) and HF (OR 2.01, 95% CI 1.15-3.50; p = 0.0141). CONCLUSIONS: In women across the menopausal age, genito-urinary symptoms, more than HF, are associated with higher values of SBP, DBP, heart rate and hypertension.

Contraception during Coronavirus-Covid 19 pandemia. Recommendations of the Board of the Italian Society of Contraception.

Purpose: The Italian Society of Contraception identified as one of its priorities the need to give recommendations on management of contraception during Coronavirus-Covid 19 pandemiaMaterials and methods: A concise communication was produced which summarises in an easy-to-read format suitable for clinicians the management of the different contraceptives mostly used. Information how to manage contraception in different conditions is presented.Results: Women may, in general, continue to use either intrauterine and or hormonal contraceptives. The use of condom should be added to any hormonal contraceptive, when the contraceptive efficacy is reduced or when women stop the contraceptive method.Conclusion: At the present time, during the Coronavirus-Covid 19 pandemia, no data contraindicate the use of intrauterine or hormonal contraceptives. Conversely the use of an appropriate contraception is advocate to prevent unintended pregnancies.

Impact of vulvovaginal atrophy of menopause: prevalence and symptoms in Italian women according to the EVES study.

This cross-sectional study included postmenopausal women, aged 45-75 years, with the aim to assess the presence of vulvovaginal atrophy (VVA) confirmed by a clinical assessment in the Italian population attending menopausal/gynecological centers. Apart from baseline variables, women scored vaginal, vulvar and urinary VVA symptoms. Impact of VVA on sexual function and quality of life (QoL) was assessed thorough EuroQoL questionnaire (EQ5D3L), Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-revised (FSDS-R). A physical examination was carried out in accordance with routine gynecological practice. VVA was confirmed in 90% of the 1226 evaluable patients (aged 59.0 ± 7.3 years). The prevalence of postmenopausal women with VVA confirmed by gynecological clinical assessment was 75.3%. The patients with VVA confirmed (n = 926) had more severe symptoms (p < .0005), lower QoL (EQ-visual analog scale, p = .008 and DIVA, p < .0005) and worsened sexual function (FSFI and FSDS-R, p < .0005 for both) when compared with the patients having nonconfirmed VVA (n = 140). VVA is highly prevalent among postmenopausal Italian women. The objective of VVA confirmation is associated with severe symptoms and impaired QoL and sexual function. A proactive approach of Italian clinicians to promote regular and early gynecological evaluation should be performed in order to delay the advancing of the disorder.

Hormone replacement therapy and prevention of chronic conditions.

Nowadays, postmenopausal women are largely undertreated. Analysis of conflicting results among different studies suggests that hormone replacement therapy (HRT) can prevent osteoporosis and cardiovascular disease in symptomatic, early postmenopausal women. In fact, climacteric symptoms are related to an increased risk of chronic conditions, including hypertension and cardiovascular disease. Different scientific societies have pointed out that patient selection, timing of initiation, and the choice of the type and dose of HRT used are the major determinants of the ultimate effect of HRT on women's health and quality of life in selected women. HRT may prevent chronic conditions when started in symptomatic women before the age of 60 years or within 10 years of the onset of the menopause, taking into consideration the characteristics and risk profiles of each given woman. The bulk of scientific evidence from preclinical, clinical, epidemiological, and also randomized studies indicates that wisely selected HRT is generally useful and rarely dangerous. Following simple and well-established rules, HRT benefits outweigh all of the possible risks. Progestogen choice can make the difference in terms of cardiovascular disease benefits.

Vaginal atrophy across the menopausal age: results from the ANGEL study.

OBJECTIVES: This study aimed to investigate the prevalence of vaginal atrophy (VA) in women across the menopausal age. METHODS: A multicenter cross-sectional investigation was performed on 747 females, 40-55 years of age, in 30 outpatient public services across the nation. The VA diagnosis was based on the combination of patient sensation of vaginal dryness, an objective sign of VA, and pH >5. RESULTS: VA was diagnosed in 36.8% of women. Prevalence ranged from 19.2% (40-45 year olds) to 53.8% (52-55 year olds). pH >5 (37.5%) was less prevalent than isolated VA symptoms or signs. Vaginal dryness (64.0%) was the most prevalent symptom followed by dyspareunia (54.5%), itching (38.5%) burning (38.3%), and dysuria (28.9%). Prevalence of vaginal signs declined from vaginal dryness (60.3%) to vaginal thinning (54.5%), vaginal pallor (47.4%), presence of petecchiae (15.7%), and mucosa fragility (15.1%). Most signs and symptoms showed an age-related increase in frequency and intensity. VA was independently associated (R2 = 0.139; p < 0.0001) with age (odds ratio [OR] 1.08; 95% confidence interval [CI] 1.03-1.13), being in postmenopause (OR 3.45; 95% CI 2.29-5.19), and presence of vasomotor symptoms (OR 3.10; 95% CI 2.09-4.60). CONCLUSION: VA and its symptoms are common in women across the menopausal age. VA identification may favor early management and treatment.

Menopausia y terapia hormonal de la menopausia. Las recomendaciones 2018 de la Unidad de Endocrinología Ginecológica de Clínica Alemana de Santiago -Sociedad Italiana de la Menopausia y la Sociedad Chilena de Endocrinología Ginecológica / Menopause and menopausal hormone therapy. The 2018 recommendations of the Gynecological Endocrinology Unit of Clínica Alemana de Santiago -Italian Society of Menopause and the Chilean Society of Gynecological Endocrinology

ABSTRACT In the last decade, the risk benefits ratio of MHT has been evaluated mainly in terms of cardiovascular risk. Present Consensus Statement is largely inspired by the Global Consensus on Menopausal Hormone Therapy in 2013 and 2016 by leading global menopause societies (The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society). The aim of these Recommendations is to provide a simple and updated reference on postmenopausal MHT. The term MHT typically includes estrogen replacement therapy (ERT) and estrogen-progestogen therapy (EPT). EPT can be sequential (Seq) when progestogen is added to ERT for 10-14 days a month, or continuous combined (CC) when progestogen is administered continuously every day along with a fixed amount of estrogen. MHT also includes Tibolone and the Tissue Selective Estrogen Complex (TSEC).

Monurelle Biogel® vaginal gel in the treatment of vaginal dryness in postmenopausal women.

OBJECTIVES: To evaluate efficacy, tolerability and safety of Monurelle Biogel® vaginal gel for treatment of vaginal dryness. METHODS: Multicenter, national, randomized, controlled vs. no-treatment, open-label study. Ninety-five postmenopausal women were randomized (48 to Monurelle Biogel® and 47 to no treatment). Primary endpoint was the change of Verbal Rating Scale (VRS) total score of vaginal atrophy (VA) symptoms after 8-week treatment. The main secondary endpoints were VRS single-item score, Vaginal Health Index (VHI) score, Maturation Index (MI), Female Sexual Function Index (FSFI), and Female Sexual Distress Scale-Revised (FSDS-R). RESULTS: The VRS total score was statistically significant in favor of the treatment group on day 28 (p = 0.001) but not on day 56 (p = 0.064). By excluding women who were not sexually active, the total VRS scores reached the criteria for clinical success in 27/43 subjects (62.8%) in the control arm and in 38/46 subjects (82.6%) in the treatment arm (p = 0.035) on day 56. The VHI score significantly changed in the active arm (4.71 ± 4.85 vs. 0.28 ± 1.71) (p < 0.001) on day 56. Even the MI significantly improved, with an increase in the percentage of superficial cells (p = 0.01). The improvements in both VHI and MI were still present at the follow-up visit after the discontinuation of the treatment (day 84). Sexual function and distress showed a statistical significant difference on day 56. CONCLUSIONS: Monurelle Biogel® vaginal gel applied twice daily for 8 weeks is effective in relieving vaginal dryness and other VA symptoms. Such a clinical meaningful effect persists at least 4 weeks and is supported by an improvement in the vaginal environment. Trial Registration clinicaltrials.gov Identifier: NCT02994342.

Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases?

Menopausal disorders may include shorter-term symptoms, such as hot flushes and night sweats (vasomotor symptoms, VMS) and longer-term chronic conditions such as cardiovascular disease (CVD), osteoporosis, and cognitive impairment. Initially, no clear link between the shorter-term symptoms and longer-term chronic conditions was evident and these disorders seemed to occur independently from each other. However, there is a growing body of evidence demonstrating that VMS may be a biomarker for chronic disease. In this review, the association between VMS and a range of chronic postmenopausal conditions including CVD, osteoporosis, and cognitive decline is discussed. Prevention of CVD in women, as for men, should be started early, and effective management of chronic disease in postmenopausal women has to start with the awareness that VMS during menopause are harbingers of things to come and should be treated accordingly.

Medical and patient attitude towards vaginal atrophy: the AGATA study.

OBJECTIVES: To provide data on current management of vaginal atrophy (VA) in a nationwide setting. METHODS: A cross-sectional, multicenter study was made in 913 postmenopausal women consulting 22 gynecological outpatient services. VA was diagnosed with a combination of subjective symptoms and objective evaluations. Women with a previous diagnosis and those with a new diagnosis of VA filled additional questionnaires regarding modalities of VA management and reasons for missing diagnosis, respectively. RESULTS: 730/913 (80%) women had ever had a diagnosis of VA. In 274 (37.5%), the diagnosis was made prior to, and in 456 (62.5%) during the investigation. Of women with a new VA diagnosis, 81.1% had never discussed their symptoms with the health-care practitioner (HCP), and 78.7% (n = 359) had never been questioned by an HCP. Of women with a previous VA diagnosis, 90.2% had been treated with systemic (10.1%), local hormonal (49.4%) or local non-hormonal (30.5%) therapy. At the time of investigation, 61.9% of these women had stopped treatment, with only 3.3% having been successfully cured. CONCLUSIONS: VA is highly prevalent in postmenopausal women. Its current management and treatment seem to be highly unsatisfactory and can be improved by medical sensitization and patient education.

Dienogest mediates midkine suppression in endometriosis.

STUDY QUESTION: What are the effects of dienogest (DNG) on midkine (MK) production in women with endometriosis? SUMMARY ANSWER: DNG-mediated down-regulation of MK in vivo and in vitro. WHAT IS KNOWN ALREADY: DNG is an oral progestin that alleviates painful symptoms of women with endometriosis with a favourable tolerability and safety profile. Its effects on MK, a growth factor that plays an important role in endometriosis, have not yet been investigated. STUDY DESIGN, SIZE, DURATION: Prospective in vivo study on 283 patients subjected to laparoscopy for benign pathologies in a University hospital and in vitro cultures of primary endometrial stromal cells (ESC) from 6 of these women with histologically confirmed endometriosis. PARTICIPANTS/MATERIALS, SETTING, METHODS: MK concentrations in the peritoneal fluid (PF) of women were measured by ELISA and compared based on endometriosis status and the use of DNG. A subsequent in vitro analysis with ESC was used to confirm the direct influence of DNG and other progestins including, norethisterone acetate (NETA) and medroxyprogesterone acetate (MPA) on MK mRNA production. MAIN RESULTS AND THE ROLE OF CHANCE: The final study population consisted of 253 women. Of these, 165 suffered from endometriosis, with 62 of them taking DNG (DNG group) and 103 taking no hormone treatment (non-DNG group) during at least 3 months before surgery. Another 88 women were endometriosis free (non-endometriosis group). The concentration of MK was highest in the PF of women in the non-DNG group (median 5.26 ng/ml, IQR 2.74-8.46). Significantly lower concentrations were found in the non-endometriosis group (median 3.51 ng/ml, IQR: 1.90-7.53, P = 0.028). The lowest concentrations were found in the DNG group (median 2.44 ng/ml, IQR: 1.12-4.70, P < 0.0001 versus non-DNG group, P = 0.048 versus non-endometriosis group). The treatment of primary cultured ESC with DNG (10(-5) M) suppressed MK mRNA production (P = 0.016), whereas MPA (P = 0.109) and NETA (P = 0.422) at same concentrations did not show a similar effect. LIMITATIONS, REASONS FOR CAUTION: The non-randomized design of the study. WIDER IMPLICATIONS OF THE FINDINGS: These findings could indicate a direct effect of DNG on endometriotic cells that could contribute to its effectiveness in the treatment of this disease. STUDY FUNDING/COMPETING INTERESTS: Funding was received from Swiss National Science Foundation (Grant No. 320030_140774). M.D.M. has received fees for speaking at scientific meetings from Bayer. The other authors have no conflicts of interest to declare.The authors state that the manufacturer of dienogest has in no way influenced the performance or outcomes of this study.

Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study.

OBJECTIVES: Prevalence of vulvar-vaginal atrophy (VVA) has been always investigated by phone or web interview without any objective evaluation. Objective signs associated with symptoms of VVA are now termed genitourinary syndrome of menopause (GSM). This multi-centric study was performed in order to provide nation-wide data on the prevalence and management of GSM. METHODS: Nine hundred thirteen females, 59.3 ± 7.4 years old asking for a routine gynecological examination were recruited. Diagnosis of GSM was based on patient sensation of vaginal dryness, any objective sign of VVA and a pH > 5. RESULTS: A 722/913 (79.1%) women were diagnosed with GSM with a prevalence ranging from 64.7% to 84.2%, starting from 1 to 6 years after menopause. Sedentary women were at higher risk of GSM (OR 1.8, 95% CI: 1.3-2.5; p = 0.0005). Recent vaginal infection was more likely in women with GSM (OR 2.48, 95% CI: 1.33-4.62; p = 0.0041). Symptoms reported by women with GSM were vaginal dryness (100%), dyspareunia (77.6%), burning (56.9%), itching (56.6%) and dysuria (36.1%). Signs detected by gynecologists were mucosal dryness (99%), thinning of vaginal rugae (92.1%), pallor of the mucosa (90.7%), mucosal fragility (71.9%) and petechiae (46.7%). Only 274 (30%) of women had had a previous diagnosis of VVA/GSM. These were treated either with no therapy (9.8%), systemic hormone (9.2%), local hormone (44.5%) or local non-hormonal (36.5%) therapy. At the time of our investigation 266 of them (97.1%) still had the disorder. CONCLUSIONS: GSM is a common, under-diagnosed and under-treated disorder. Measures to improve its early detection and its appropriate management are needed.

Relation between oxidative stress and climacteric symptoms in early postmenopausal women.

OBJECTIVES: To evaluate the relation between climacteric symptoms or other risk factors for cardiovascular disease and oxidative status of postmenopausal women. METHODS: Cross-sectional investigation performed at the outpatient service for the menopause at the University Hospital, on 50 apparently healthy women in physiological postmenopause. The whole-blood free oxygen radical test (FORT), free oxygen radical defence (FORD), age, months since menopause, weight, body mass index, waist circumference, waist-to-hip ratio, estradiol, lipids, glucose, insulin, insulin resistance (glucose/insulin and HOMA-IR), and fibrinogen were evaluated. The Greene Climacteric Scale with its subscales was used to evaluate climacteric symptoms. The pulsatility index, an index of downstream blood flow resistance, was determined for both the internal carotid artery and the brachial artery. RESULTS: The waist-to-hip ratio (r = 0.540; p = 0.0001), estradiol (r = 0.548; p = 0.0004) and waist circumference (r = 0.345; p = 0.02) were independently related to blood FORT. The score in the Greene vasomotor subscale was the only parameter independently related to blood FORD (r = 0.554; p = 0.0001). FORT was not related to the artery pulsatility index, while FORD was negatively related to the pulsatility index of both the internal carotid (r = 0.549; p = 0.0001) and the brachial (r = 0.484; p = 0.0001) arteries. DISCUSSION: In postmenopausal women, abdominal adiposity and hypoestrogenism increase oxidative stress. Climacteric symptoms, particularly vasomotor symptoms, markedly reduce antioxidant defences. Lower antioxidant defences are associated with higher resistance to blood flow in the great arteries. In women early after the menopause, visceral fat, hypoestrogenism and climacteric symptoms may increase the risk for cardiovascular disease.