Estrogen deprivation can cause vaginal atrophy symptoms. Frequency and determinants of urogenital symptoms in postmenopausal Islamic women

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1 Menopause: The Journal of The North American Menopause Society Vol. 21, No. 2, pp. 000/000 DOI: /gme.0b013e * 2013 by The North American Menopause Society Frequency and determinants of urogenital symptoms in postmenopausal Islamic women Yunus Aydin, MD, 1 Hikmet Hassa, MD, 1 Tufan Oge, MD, 1 Omer Tarik Yalcin, MD, 1 and Fezan yahin Mutlu, PhD 2 Abstract Objective: The objective of this study was to evaluate the frequency of genitourinary symptoms and their relationships with several factors in a large cohort of postmenopausal women in Turkey. Methods: We performed a cross-sectional study to review genitourinary complaints among 1,328 postmenopausal women; 1,071 of these women were enrolled in the study. They were questioned about their vaginal and urinary symptoms, and the relationships between these symptoms and their demographic characteristics were evaluated. Results: The most common vaginal and urinary symptoms were dryness (n = 358; 33.4%) and nocturia (n = 421; 39.3%), respectively. Cigarette smoking and regular exercise were not associated with any vaginal symptoms (P ), with the exception of an association between regular exercise and vaginal dryness (P = 0.026). Nocturia was more common in women older than 60 years (P = 0.001) and in obese women (P = 0.013). Based on multiple binary logistic regression analysis, lower educational status (primary school vs secondary school or higher) and higher parity were the factors most significantly associated with the appearance of at least three vaginal symptoms. Lower educational status was associated with vaginal pain (P = 0.002; odds ratio [OR], 1.75), itching (P G 0.001; OR, 1.23), and discharge (P = 0.011; OR, 1.46). Higher parity was associated with vaginal itching (P G 0.001; OR, 1.23), discharge (P = 0.07; OR, 1.18), and burning (P = 0.012; OR, 1.16). Body mass index (BMI) was the only factor that was significantly associated with the appearance of at least three urinary symptoms, with each one-unit increase in BMI increasing the risk of urgency (P G 0.001; OR, 1.06), nocturia (P G 0.001; OR, 1.06), and frequency (P = 0.009; OR, 1.04). Conclusions: We identify associations between the frequency of genitourinary complaints and educational status, parity, and BMI. There is no association between regular exercise and urogenital symptoms. However, prospective studies are needed to evaluate the effects of regular exercise on urogenital symptoms. When examining postmenopausal women with risk factors for urinary and vaginal symptoms, clinicians should evaluate these symptoms more thoroughly to facilitate earlier treatment. Key Words: Exercise Y Genitourinary symptoms Y Lifestyle Y Menopause Y Urinary symptoms Y Vaginal symptoms. Estrogen deprivation can cause vaginal atrophy symptoms and vasomotor symptoms, which critically diminish quality of life in postmenopausal women. Although climacteric symptoms, particularly vasomotor symptoms, may be transient, atrophic symptoms affecting the vagina and lower urinary tract are often progressive and frequently require treatment. 1 Despite the high prevalence and diversity of urogenital symptoms, only 20% to 25% of symptomatic women seek medical help; most women avoid complaining about vaginal Received January 9, 2013; revised and accepted March 21, From the Departments of 1 Obstetrics and Gynecology and 2 Biostatistics, Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey. The authors alone are responsible for the content and drafting of this manuscript. Funding/support: None. Financial disclosure/conflicts of interest: None reported. Address correspondence to: Tufan Oge, MD, Department of Obstetrics and Gynecology, Eskisehir Osmangazi University School of Medicine, Eskisehir 26100, Turkey. tufanoge@gmail.com and urinary symptoms during their postmenopausal years, which may be attributable to cultural values and the acceptance of these symptoms as a normal aspect of aging. 2,3 Studies evaluating the frequency of urogenital symptoms and the factors associated with such symptoms face obstacles because of the embarrassment experienced by women when discussing these issues in the context of different cultures, particularly in Islamic societies. Although several multinational studies have evaluated vaginal and urologic symptoms in postmenopausal women, 3<7 only a few such studies have been conducted in Turkey. 8<11 Moreover, with the exception of multinational studies, many studies have included limited numbers of participants. With the goal of overcoming this research deficit, we aimed to determine the frequency of genitourinary symptoms and their associated factors in a large cohort of postmenopausal womeninturkey. To the best of our knowledge, this study includes one of the largest numbers of participants from a single institute in the English literature and in Turkey. Menopause, Vol. 21, No. 2,

2 AYDIN ET AL METHODS After obtaining institutional review board approval, we performed a cross-sectional study to review women s genitourinary complaints. Of the 1,328 postmenopausal women who attended the outpatient clinic from 2005 to 2012 and expressed interest in enrolling in the study, which involved completing a questionnaire about urogenital complaints, 1,071 women were eligible for the study. The enrolled women had undergone spontaneous menopause, defined as the absence of menstrual bleeding within the previous 12 months and a serum follicle-stimulating hormone level higher than 40 miu/ml. Women who are currently using or had ever used systemic or local hormone therapy (n = 83) or who had a history of any gynecological or urogynecological surgical operation (n = 72), cancer (n = 2), drug intake (n = 25), or renal or urinary tract disease (n = 19) were excluded from the study. Moreover, 56 women declined to enroll in the study. The women underwent a routine pelvic examination during their visit, and those with pelvic organ prolapse of any vaginal compartment with a Baden classification greater than grade II were excluded from the study. 12 The women completed a questionnaire during a face-to-face interview. The questionnaire included questions about their age, parity, age at menopause, length of menopause, body mass index (BMI), lifestyle (including regular exercise and smoking status), and the presence of urogenital symptoms. Regular exercise was defined as a 30-minute exercise session more than two times per week. Smoking status was determined according to an answer of Byes[ or Bno,[ regardless of the women s past cigarette smoking habits or exposure to smoke. A validated questionnaire was used to evaluate genitourinary symptoms. The women were asked about their vaginal symptoms, including vaginal pain, dyspareunia, itching, discharge, burning, dryness, and postcoital bleeding. They were also questioned about their urinary symptoms, including dysuria, frequency, urgency, nocturia, and incontinence. The symptoms were coded as either Babsent[ or Bpresent.[ 8 The reliability of these symptoms, according to Cronbach s > coefficient, was The relationships between the presence of symptoms and the women s demographic characteristics, reproductive histories, and lifestyles were evaluated based on their answers to the questionnaire. Statistical analysis was performed using IBM SPSS Statistics 20.0 software. For categorical variables, Pearson s W 2 test was used. Data are presented as n (%). P G 0.05 was set as the significance threshold. Odds ratios (ORs) and 95% CIs were also calculated. Multiple binary logistic regression analysis was used to evaluate age, parity, BMI, and length of menopause as noncategorical factors. Regular exercise (yes vs no), smoking status (smoker vs nonsmoker), and educational status (primary school vs secondary school or higher) were evaluated as categorical factors. The relationships between these factors and the appearance of all separately analyzed vaginal and urinary symptoms were assessed. Four to seven steps of backward logistic regression analyses were applied, and vaginal and urinary symptoms were found to be associated with at least one of the above seven factors. Therefore, we attempted to identify factors that could be associated with the appearance of at least three urinary symptoms, vaginal symptoms, or both. Multiple binary logistic regression analysis was performed with an entry probability of 0.05 and a removal probability of RESULTS The participants mean age, parity, BMI, length of menopause, and age at menopause were 50.4 (4.72) years, 2.4 (1.22), 27.4 (4.12) kg/m 2, 40.1 (45.37) months, and 47.1 (3.62) years, respectively. Answers to lifestyle questions indicated that 295 (27.5%) of the women smoked cigarettes and 506 (47.3%) did not exercise regularly. In addition, 580 (54.2%) of the women had attained at least a high school degree. The descriptive characteristics of the participants are summarized in Table 1. Among the 1,071 study participants, the most common vaginal and urinary symptoms were dryness (n = 358; 33.4%) and nocturia (n = 421; 39.3%), respectively. The urinary symptoms nocturia, frequency, incontinence, and urgency were reported more frequently than any of the vaginal symptoms. The frequencies of all reported vaginal and urinary symptoms are summarized in Table 2. Vaginal pain, itching, and discharge were significantly higher in women with higher parity (n 9 2) and education. Smoking and regular exercise were not associated with any of the vaginal symptoms (P ), with the exception of a correlation between regular exercise and vaginal dryness (P = 0.026).The relationships between vaginal symptoms and age, parity, BMI, educational status, length of menopause, smoking status, and exercise habits are shown in Table 3. With respect to urinary symptoms, dysuria (P = 0.001) and urgency (P = 0.021) were more common among higher-parity TABLE 1. Descriptive characteristics of the participants n (%) Age, y (44.1) Q (55.9) Parity (62.4) (37.5) Body mass index, kg/m 2 G (73.7) Q (26.3) Educational status Primary school 491 (45.8) Secondary school or higher 580 (54.2) Length of menopause, mo (43.8) (22.2) (13.6) (4.2) Q (16.2) Cigarette smoking Yes 295 (27.5) No 776 (72.5) Regular exercise Yes 565 (52.7) No 506 (47.3) 2 Menopause, Vol. 21, No. 2, 2014 * 2013 The North American Menopause Society

3 UROGENITAL SYMPTOMS IN POSTMENOPAUSAL WOMEN TABLE 2. Frequency of reported vaginal and urinary symptoms n (%) Vaginal symptoms Dryness 358 (33.4) Discharge 322 (30.1) Itching 220 (20.5) Dyspareunia 219 (20.4) Burning 205 (19.1) Vaginal pain 180 (16.8) Postcoital bleeding 53 (4.9) Urinary symptoms Nocturia 421 (39.3) Frequency 412 (38.5) Incontinence 394 (36.8) Urgency 385 (35.9) Dysuria 197 (18.4) women (n 9 2). Nocturia occurred more frequently in obese women (P = 0.013) and nonsmokers (P = 0.036). Women with higher parity (P G 0.001), lower educational status (P = 0.007), and higher BMI (P = 0.019) were more frequently concerned about urinary incontinence. The relationships between the women s demographic characteristics and urinary symptoms are summarized in Table 4. A logistic regression analysis demonstrated that lower educational status and parity were the factors most significantly associated with the appearance of at least three vaginal symptoms. Lower educational status was associated with vaginal pain (P = 0.002; OR, 1.75), itching (P G 0.001; OR, 1.23), and discharge (P = 0.011; OR, 1.46). Higher parity was associated with vaginal itching (P G 0.001; OR, 1.23), discharge (P = 0.007; OR, 1.18), and burning (P = 0.012; OR, 1.16). BMI was the only factor that was significantly associated with the appearance of at least three urinary symptoms, with each one-unit increase in BMI increasing the risk of urgency (P G 0.001; OR, 1.06), nocturia (P G 0.001; OR, 1.06), and frequency (P = 0.009; OR, 1.04; Table 5). DISCUSSION Women spend nearly one third of their lives in the postmenopausal period, and genitourinary complaints are a common concern during this period. In the present study, urinary and vaginal symptoms were reported by nearly one third of women. Higher-parity women more frequently reported the vaginal symptoms pain, itching, and discharge, as well as the urinary symptoms dysuria, urgency, and incontinence. Women with higher educational status experienced more vaginal dryness, and those with less education reported more vaginal pain, itching, and discharge. Moreover, obese women reported more urinary complaints, including nocturia and incontinence, whereas they were less likely to experience dyspareunia. Neither regular exercise nor smoking was associated with most of the genitourinary complaints. This study included one of the largest numbers of participants among studies evaluating genitourinary complaints in postmenopausal women in the English literature. The size of our study cohort is noteworthy because the results of this studymay reflect social approaches to genitourinary complaints; discussing the vagina and references to postmenopausal complaints are traditionally perceived as taboo in Islamic countries. In addition, the present study focused on each vaginal or urinary symptom analyzed, and we investigated the relationships between these symptoms and different demographic characteristics. However, this study was limited by its retrospective methodological design. This type of study involves inherent biases, including selection and information biases. For example, women with pelvic organ prolapse of any vaginal compartment with a Baden classification greater than grade II were excluded from this study. Because prolapse may cause genitourinary symptoms, we excluded these women and others who potentially experienced the evaluated symptoms because of factors unrelated to postmenopausal issues. Our other exclusion criteria, which were chosen because our primary aim was to investigate the frequency of genitourinary symptoms, may have also contributed to selection bias. In addition, our results may have been affected by reverse causation bias. Women may refrain from exercise because of genitourinary symptoms, which might obscure the true relationship between regular exercise and genitourinary symptoms. Another important limitation of the study was the lack of objective methods for calculating the severity of vaginal and urinary symptoms. However, to our knowledge, no objective methods are available for calculating all of these symptoms. Finally, our hospital-based study design may have identified women who were more or less likely to experience urogenital symptoms compared with other women. Despite these limitations, our study enrolled the largest number of participants from a single clinic among studies in the English literature evaluating genitourinary complaints in postmenopausal women, which may help to elucidate the frequency of these genitourinary symptoms. Bozkurt et al evaluated the prevalence and risk factors of urogenital symptoms in postmenopausal women and found that no more than 20% of the women had urinary and vaginal complaints. They also found that the presence of symptoms was related to women s age, parity, time since menopause, and use of hormone therapy. 10 Studies of vaginal atrophy and new treatments for its symptoms have revealed that an estimated 10% to 40% of postmenopausal women experience symptoms related to urogenital atrophy, whereas only 10% to 20% of symptomatic women seek medical help. 2,10 Moreover, a multinational study from 11 countries reported that the prevalence of vaginal dryness ranged from 5.8% to 19.7%. 6 In the present study, we observed that nearly one third of the women had genitourinary complaints and that the factors most significantly associated with these symptoms were educational status, parity, and BMI. Whether there is an association between urinary incontinence and menopause is the subject of debate. 13,14 However, we found significant correlations between incontinence and higher educational status, parity, and BMI, but not between incontinence and age or menopause duration. Cultural factors and social status have been found to be important parameters with respect to the experience of menopausal Menopause, Vol. 21, No. 2,

4 AYDIN ET AL TABLE 3. Associations between participants characteristics and vaginal symptoms Vaginal pain Dyspareunia Vaginal itching Vaginal discharge Vaginal burning Vaginal dryness Postcoital bleeding n(%) P n(%) P n(%) P n(%) P n(%) P n (%) P n (%) P Age, y (16.7) (21.6) (19.2) (33) (18.4) (33.8) (4.4) Q (16.9) 117 (19.6) 129 (21.6) 166 (27.8) 118 (19.7) 198 (33.1) 32 (5.4) Parity (14.8) (21.8) (17.8) (26.9) (17.6) (35.0) (5.1) (20.1) 73 (18.2) 101 (25.1) 142 (35.3) 87 (21.6) 124 (30.8) 19 (4.7) Body mass index, kg/m 2 G (16.7) (21.9) (20.5) (31.0) (19.0) (33.7) (5.3) Q30 48 (17.1) 46 (16.4) 58 (20.6) 77 (27.4) 55 (19.6) 92 (32.7) 11 (3.9) Educational attainment Primary school 104 (21.2) G (18.5) (23.6) (34.8) (21.6) (29.9) (5.1) Secondary school or higher 76 (13.1) 128 (22.1) 104 (17.9) 151 (26.0) 99 (17.1) 211 (36.4) 28 (4.8) Length of menopause, mo (17.4) (21.1) (21.5) (36.0) (19.6) (31.5) (3.4) (16.5) 49 (20.8) 41 (17.4) 63 (26.7) 42 (17.8) 84 (35.6) 13 (5.5) (13.7) 27 (18.5) 36 (24.7) 30 (20.5) 27 (18.5) 47 (32.2) 10 (6.8) (11.1) 3 (6.7) 8 (17.8) 13 (28.9) 6 (13.3) 9 (20.0) 1 (2.2) Q81 34 (19.5) 41 (23.6) 34 (19.5) 47 (27.0) 38 (21.8) 70 (40.2) 13 (7.5) Cigarette smoking Yes 55 (18.6) (22.7) (17.6) (26.4) (15.9) (34.2) (3.1) No 125 (16.1) 152 (19.6) 168 (21.6) 244 (31.4) 158 (20.4) 257 (33.1) 44 (5.7) Regular exercise Yes 92 (16.3) (20.2) (18.9) (27.6) (17.7) (36.5) (5.5) No 88 (17.4) 105 (20.8) 113 (22.3) 166 (32.8) 105 (20.8) 152 (30.0) 22 (4.3) P G 0.05 was considered significant. Values in bold indicate P values that are statistically significant. 4 Menopause, Vol. 21, No. 2, 2014 * 2013 The North American Menopause Society

5 UROGENITAL SYMPTOMS IN POSTMENOPAUSAL WOMEN TABLE 4. Associations between participants characteristics and urinary symptoms Dysuria Frequency Urgency Nocturia Incontinence n (%) P n (%) P n (%) P n (%) P n (%) P Age, y (20.1) (37.6) (34.2) (38.7) (34.9) Q (17.1) 234 (39.1) 223 (37.3) 238 (39.8) 229 (38.3) Parity (15.4) (37.7) (33.3) (37.5) (32.1) G (23.4) 160 (39.8) 162 (40.3) 170 (42.3) 179 (44.5) Body mass index, kg/m 2 G (19.2) (37.3) (34.7) (37.1) (34.4) Q30 45 (16.0) 117 (41.6) 111 (39.5) 128 (45.6) 122 (43.4) Educational attainment Primary school 101 (20.6) (38.5) (36) (42.4) (40.5) Secondary school or higher 96 (16.6) 223 (38.4) 208 (35.9) 213 (36.7) 195 (33.6) Length of menopause, mo (17) (35.5) (36.2) (36.4) (35.3) (19.9) 99 (41.9) 85 (36.0) 97 (41.1) 95 (40.3) (17.1) 55 (37.7) 53 (36.3) 59 (40.4) 52 (35.6) (11.1) 16 (35.6) 9 (20.0) 14 (31.1) 17 (37.8) Q81 40 (23) 75 (43.1) 68 (39.1) 80 (46.0) 64 (36.8) Cigarette smoking Yes 44 (14.9) (39.7) (39.3) (34.2) (34.9) No 153 (19.7) 295 (38.0) 269 (34.7) 320 (41.2) 291 (37.5) Regular exercise Yes 99 (17.5) (39.5) (37.7) (38.9) (37.2) No 98 (19.4) 189 (37.4) 172 (34.0) 201 (39.7) 184 (36.4) P G 0.05 was considered significant. Values in bold indicate P values that are statistically significant. TABLE 5. Results of multiple binary logistic regression analysis A P Odds ratio (95% CI) a Possible factors affecting at least three vaginal symptoms Educational attainment (primary school vs secondary school or higher) j ( ) Parity (for every one-unit increase) G ( ) Possible factors affecting at least three urinary symptoms Body mass index (for every one-unit increase) G ( ) a The most robust odds ratio among the genitourinary symptoms is presented. symptoms. 15 Educational status, a factor analyzed in the present study, may be a predictor of women s social status. However, the examination of educational status may have introduced bias to the study because women with lower educational status may be more likely to avoid discussing vaginal dryness. With respect to lifestyle, although the effects of exercise on genitourinary complaints are not well documented, regular exercise has been found to effectively reduce menopausal symptoms, particularly hot flashes. 16,17 In the present study, vaginal dryness was more common (P = 0.026) among women who exercised regularly, although no associations between any other genitourinary symptoms and either exercise or cigarette smoking were detected. Although menopause is a normal physiological event in a woman s life, genitourinary symptoms have important effects on quality of life. Therefore, clinicians should be aware of these symptoms and should encourage women to discuss any urinary and vaginal symptoms. Further studies are needed to identify the effects of cultural differences on women s attitudes toward genitourinary complaints. CONCLUSIONS This study identifies associations between the frequency of genitourinary complaints and educational status, parity, and BMI. No association between regular exercise and urogenital symptoms has been identified. However, prospective studies are needed to evaluate the effects of regular exercise on urogenital symptoms. When examining postmenopausal women with risk factors for urinary and vaginal symptoms, clinicians should evaluate these symptoms more thoroughly to facilitate earlier treatment. REFERENCES 1. Sturdee DW, Panay N. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric 2010;13: Archer DF. Efficacy and tolerability of local estrogen therapy for urogenital atrophy. Menopause 2010;17: Nappi RE, Davis SR. The use of hormone therapy for the maintenance of urogynecological and sexual health post WHI. Climacteric 2012; 15: Nelson DB, Sammel MD, Patterson F, Lin H, Gracia CR, Freeman EW. Effects of reproductive history on symptoms of menopause: a brief report. Menopause 2011;18: Blümel JE, Chedraui P, Baron G, et al. A large multinational study of vasomotor symptom prevalence, duration, and impact on quality of life in middle-aged women. Menopause 2011;18: Leiblum SR, Hayes RD, Wanser RA, Nelson JS. Vaginal dryness: a comparison of prevalence and interventions in 11 countries. J Sex Med 2009;6: Huang AJ, Luft J, Grady D, Kuppermann M. The day-to-day impact of urogenital aging: perspectives from racially/ethnically diverse women. J Gen Intern Med 2010;25: Menopause, Vol. 21, No. 2,

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