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"Advancing age means more dependence on the resources of our family, our friends, and our community. It also means needing access to healthcare professionals who have advanced training for caring for elderly patients. You wouldn’t take your child to a regular General Practitioner, but rather a pediatrician. So, why would an elderly person not be taken to a physician specializing in gerontology? This is one question and it is of great importance because of the physiology and the psychology at play here."

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Elderly individuals, we've come to understand, suffer from anxiety disorders just like the rest of us. Older women, in fact, may actually develop panic as they grow older, and when we consider why we begin to understand the problems here.

Advancing age means more dependence on the resources of our family, our friends, and our community. It also means needing access to healthcare professionals who have advanced training for caring for elderly patients. You wouldn't take your child to a regular General Practitioner, but rather a pediatrician. So, why would an elderly person not be taken to a physician specializing in gerontology? This is one question and it is of great importance because of the physiology and the psychology at play here.

Now a new study has found that too many communities are not ready to meet the needs of their aging populations. Access isn't provided in living spaces, buses, or restaurants. Meals needed by the shut-in elderly may be delivered sporadically, but who looks in the community for those who haven't applied because they didn't have the knowledge or the energy? Medications may be needed, but can they afford them and are they being given in the proper amounts and at the right times?

How can you help? Each of us has to look in our area for the gaps and the things overlooked. It's not just a service we owe to our older citizens, we owe it to ourselves, so it meets two needs.

Related Topics: Long-term Antidepressants for Elderly?, Anxiety Often Missed in the Elderly

Posted by: Patricia Farrell, PhD at 2:52 pm

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The Anxiety of the Elderly " Anxiety and Stress Management

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Elderly individuals, we've come to understand, suffer from anxiety disorders just like the rest of us. Older women, in fact, may actually develop panic as they grow older, and when we consider why we begin to understand the problems here. Advancing age means more dependence on the resources of our family, our friends, and our community.

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Is your sleep different than it used to be when you were younger? It happens to a lot of people.

Nearly half of men and women over the age of 65 say they have at least one sleep problem. With age, many people get insomnia or have other sleep disorders.

It's true that as we get older, our sleep patterns change. In general, older people sleep less, wake up and go back to sleep more often, and spend less time in deep sleep or dreaming than younger people.

But at any age, you still need quality rest to be healthy.

Some common reasons include:

Poor sleep habits: If you don't keep a steady schedule for going to bed and waking up, it can affect your body's internal clock and make it even harder to get good sleep. Also, at any age, it's a minus if you drink alcohol before bedtime, nap too much, or stay in bed when you're not sleeping.

Medications: Some drugs make it harder to fall or stay asleep, or even stimulate you to stay awake. If you think that might be true for you, ask your doctor to check.

Worry, stress, or grief. Aging brings many life changes. Some are positive. Others are really hard. When you lose someone you love, move from your family home, or have a condition that changes your life, that can cause stress, which can hamper your sleep.

If changes like these affect you or an aging loved one, talk with your doctor or a counselor. It could help ease your mind so you can sleep better.

Sleep disorders: Besides insomnia, these include apnea, restless legs syndrome, periodic limb movement disorder, and REM behavior disorder. Your doctor can see if you have one of these conditions.

Too much downtime. Many people stay active well into their golden years. But if your days are too idle, you may find it harder to get good sleep.

Everyone is different. If you sleep less than when you were younger but still feel rested and energetic during the day, it might be that you now need less sleep.

But if you have noticed that your lack of sleep affects you during the day, tell your doctor. There are steps you can take to get better rest. Many are simple tweaks to your daily routine, like setting a regular bedtime, being more active, and taking steps to ease your mind before you hit the hay.

Sources

Wolkove, N. Canadian Medical Association Journal, April 24, 2007.

National Heart, Lung, and Blood Institute.

The National Sleep Foundation.

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Is your sleep different than it used to be when you were younger? It happens to a lot of people. Nearly half of men and women over the age of 65 say they have at least one sleep problem. With age, many people get insomnia or have other sleep disorders.

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Oct. 4, 2001 -- Have you ever heard, "Don't mind Steven, he's just going through the change of life?" That's right -- "he," not "she." According to some researchers, the idea may not be so far-fetched.

The concept of a " male menopause" and the need for hormone replacement therapy as a treatment is still highly controversial, but you wouldn't know that from one doctor's attempt to recruit men for his study. Jerald Bain, MD, set out to find 100 subjects to participate in his study -- 900 volunteered for the chance to get a male hormone pill for what ailed them.

In the end, Bain, who is an endocrinologist at Toronto's Mount Sinai Hospital and the director of the Health Institute for Men at the King's Health Center in Toronto, was only able to use 30 subjects. His data has now been collected and he is analyzing it. He contends that "there is no basis for the assumption that the male hormone, testosterone, is dangerous."

Andrew Dott, MD, and Anthony Karpas, MD, of the Institute of Endocrinology and Reproductive Medicine in Atlanta, contend that about 40% of 40-something men experience these symptoms to some degree:

lethargy, or fatigue

depression

increased irritability

mood swings

loss of bone density

decrease in lean muscle

increase in fat

anemia, or low blood levels of iron

decreased libido

difficulty in attaining and sustaining erections

They say that these symptoms of "male menopause," also called andropause or viropause, can result from a decreased level of the male hormone testosterone and/or some of these risk factors:

According to Bain, until recently, most doctors have considered these symptoms just part of aging and have ignored them. But now, he says, "we're beginning to realize we don't have to accept them all. We can accept the loss of strength, but to have to lie in bed at age 60 because of weakness and fatigue is not something we should accept."

Although men can experience a decline in testosterone levels with increasing age, and despite 150 years of attempts to rejuvenate men with hormone replacements, "male menopause" is still widely ignored. Malcolm Carruthers, a British specialist in men's health with a practice in London, suspects that one reason is historical.

Continued

The first successful use of hormone replacement was carried out 150 years ago by a German professor named Berthold who transplanted a rooster's testes into another castrated rooster. This procedure prevented the castrated rooster's comb from withering away. That study was followed by numerous other experiments using testicular transplants and extracts.

Testosterone was only isolated and synthesized 60 years ago. However, the oral form can be toxic to the liver and heart, and that, Carruthers says, has "colored the thinking of two generations of physicians."

Another problem associated with the diagnosis of "male menopause" is that only about 13% of men with symptoms have a low total testosterone level. Carruthers and others, however, say doctors need to evaluate the level of free active testosterone, or FAT, rather than total testosterone levels. FAT is obtained by dividing the total plasma testosterone level by that of the sex hormone binding globulin, or SHBG. This turns out to be low in 74% of the men with menopausal symptoms. SHBG increases with age and "zaps" the free testosterone before it can get into the cells to do its job.

Skeptics of andropause still abound. In an article in American Journal of Psychiatry, UCLA psychiatrist H. Sternbach concluded that "testosterone decline/deficiency is not a state strictly analogous to female menopause and may exhibit considerable overlap with primary and other secondary psychiatric disorders."

British urologists N. Burns-Cox and C. Gingell concluded in another medical journal that "the symptoms of the andropause fatigue can readily be explained by stress, and there is no scientifically valid ... study that shows any benefit for testosterone supplements in this uncommon group of patients."

Carruthers, however, has been following men who have taken testosterone supplements for up to five years, and he has concluded that the supplements cause no negative effects on their hearts, livers, or prostates.

And Dott and Karpas point out that when it comes to diagnosis, doctors should not just evaluate testosterone levels. "Good medical care dictates that a comprehensive medical and psychological assessment along with a thorough laboratory assessment are necessary," they say.

Possibly this debate will be solved once Bain completes his analysis of data comparing men with "menopausal" symptoms on hormone replacement with men receiving placebos. If so, will men rush out to get hormone replacement therapy? Stay tuned!

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Oct. 4, 2001 -- Have you ever heard, "Don't mind Steven, he's just going through the change of life?" That's right -- "he," not "she." According to some researchers, the idea may not be so far-fetched.

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Male menopause or otherwise known as andropause or hypogonadism affects nearly 6 million men each year. Symptoms include:

Low sex drive and infertility

Development of "moobs" or male breasts, sometimes with painful swelling

Shrunken testicles

Erectile dysfunction

Hot flashes

Osteopenia\osis

Anemia

Depression\anger\foggy thinking

By the way, balding is NOT one of the symptoms of a low testosterone level - more often than not, you can chalk that male pesky problem up to genetics though the loss of hair on other parts of the body can be a sign of low testosterone.

Treatment: Injections, pellets, pills, creams, and patches are typical treatment options for those who have been diagnosed with low testosterone, but surprisingly most men who suffer from andropause don't know they have it or think about seeking medical advice because they attribute their symptoms to the aging process. There are some potential concerns about testosterone replacement surgery, especially for men who have a history of breast or prostate cancer. By the way, you can also find an excellent article on andropause on WebMD.
Diet and lifestyle tips:
Diet can affect testosterone levels to a certain extent, but most men who meet the criteria of low testosterone will most likely require more reliable medical treatment. Still, these tips could prove helpful:

1. Don't drink too much! Alcohol helps in the conversion of testosterone to estrogen so it's best to heed the American Heart Association recommendations of no more than two alcoholic beverages a day - unless you want to sport male breasts.

2. Watch the belly fat. Men with type II diabetes and those diagnosed with metabolic syndrome (a combination of risk factors such as larger waists, elevated blood glucose, high blood pressure, and high triglycerides) are much more likely to have low testosterone levels. It's a vicious cycle - low testosterone increases belly fat and belly fat drives down testosterone production.

3. Lean on protein: Include adequate quantities of high-quality protein from dairy and lean meat, which can also help increase testosterone. Ranges of 1.0-1.2 grams per kilogram of body weight may be more appropriate.

4. Go "mono y mono": Include more monounsaturated fat sources like avocado, canola and olive oil, and almonds, which have been shown to boost resting levels of testosterone.

5. Eat Zinc and copper-rich foods. Zinc and copper boost testosterone levels and also help in increasing the quality and quantity of sperm. Foods like oysters, beef, crab, pork, turkey, mushrooms, and chocolate are great sources of zinc and copper.

So guys, if any of those signs of low testosterone pop up in your life, be sure to have a talk with your doctor. In the meantime, include those manly foods I mentioned...yes, that's right, chocolate is a man's food, too!

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Male menopause or otherwise known as andropause or hypogonadism affects nearly 6 million men each year.

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There's a lot of information going around that says that as men age, they get moodier, more irritable, and easily frustrated -- kind of like a " male menopause."

Some say this happens because their testosterone levels start to go down. But can a lack of one hormone really create a bunch of grumpy, older men?

"It's nonsense," says Bradley Anawalt, MD, chief of medicine at the University of Washington. "Older men are irritable -- it's almost never due to testosterone."

The science doesn't point to a single right answer. But some experts do see a link between low testosterone levels (or "low T") and mood shifts in aging men.

Generally, men make less testosterone as they get older. Forty percent over age 45 have levels that doctors consider below the norm (<300 ng/dL). Problems with the testicles or the pituitary gland can cause it. It can also be linked to a number of ailments, like high blood pressure and diabetes. Many times, doctors can't pinpoint the cause.

Some symptoms, like low sex drive, loss of bone density, and loss of muscle mass are linked to low testosterone. But Abraham Morgentaler, MD, founder and director of Men's Health Boston medical clinic, says he often sees other side effects in his patients. "Men with low testosterone find that their emotional reserves are lower," he says. "They have a shorter fuse. In popular culture, people link male anger with high testosterone, but as a rule we see it more in men with low testosterone -- most commonly when levels are dropping. That's when men get cranky."

There's some research that shows that men with low T even have hot flashes just like women do during menopause.

But other studies show that what's going on inside a man's body as he reaches late-middle age is far different than what happens to a woman. During menopause, the production of estrogen drops sharply. Men tend to lose testosterone gradually, about half a percent per year.

Continued

For some doctors, a "male menopause" caused by slowly decreasing testosterone is too far of a leap. Alvin Matsumoto, MD, professor at the University of Washington School of Medicine, says that sexual symptoms, like low libido, poor sexual performance, and erectile dysfunction have strong links to lower levels of the hormone. But the studies he's seen show that other symptoms, like fatigue, depression, and mood issues, aren't necessarily tied to low T.

"I think it's a little naive to think it's all related to testosterone," Matsumoto says. "I think there are a lot of things going on when you get older."

He points to the fact that a majority of aging men experience low T as a side effect of other chronic problems, like obesity and high cholesterol. If your beer gut is starting to make your back hurt and slowing you down, you're more apt to be grumpy, right? And even if testosterone is an issue, causing problems in the bedroom, for example, maybe it's that, not the hormone level, that's got you in a sour mood.

"If you're androgen deficient and you're experiencing a low sex drive, will you get a little irritable?" Matsumoto asks. "Yes!"

So what can you do if you're getting older, your testosterone is in decline, and you feel unusually moody or irritable?

If your levels are consistently low and you show multiple symptoms, like fatigue or malaise, some doctors might recommend hormone therapy. "Low testosterone affects our quality of life," Morgentaler says. "Some people might say it's a normal part of aging. Well, so is declining vision, but that doesn't mean we don't treat it."

Ronald Swerdloff, MD, a spokesperson for the National Institute on Aging, says there's some truth to that. "I'm not aware that low testosterone is responsible for grumpy old men," he says. "But people with low testosterone have been shown to have a decrease in mood, and there is some evidence that treatment will improve that."

Continued

But Anawalt and Matsumoto say that regardless of whether you believe there's such a thing as irritable male syndrome that's caused by low T, the best way to feel better is to tackle your overall health.

"I don't think you should be paying attention to testosterone levels," Matsumoto says. "Pay attention to how you feel. Pay attention to the things that everybody knows are good for you, like diet, exercise, weight control, not smoking or drinking too much. Even though testosterone is my area, I believe these things are much more effective in getting people to feel better. And maybe a little less irritable."

Sources

SOURCES:

Brawer, M. Reviews in Urology, published online 2004.

Bradley Anawalt, MD, chief of medicine, University of Washington Medical Center; spokesperson, Endocrine Society.

Home Health Network: "Hypogonadism."

Abraham Morgentaler, MD, founder and director, Men's Health Boston.

Steward: "Andropause: Do Men Go Through Menopause Too?"

Alvin Matsumoto, MD, professor, University of Washington School of Medicine; spokesperson, National Institute on Aging.

Ronald Swerdloff, MD, chief, division of endocrinology, department of medicine, David Geffen School of Medicine, UCLA; spokesperson, National Institute on Aging.

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Irritable Male Syndrome: Fact or Fiction?

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There's a lot of information going around that says that as men age, they get moodier, more irritable, and easily frustrated -- kind of like a " male menopause." Some say this happens because their testosterone levels start to go down. But can a lack of one hormone really create a bunch of grumpy, older men?

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Male menopause: Myth or reality?

Aging-related hormone changes in men - sometimes called male menopause - are different from those in women. Understand signs, symptoms and treatment options.
By Mayo Clinic Staff
Hormone changes are a natural part of aging. Unlike the more dramatic reproductive hormone plunge that occurs in women during menopause, however, sex hormone changes in men occur gradually. Here's what to expect, and what you can do about it.

Debunking the male menopause myth

The term "male menopause" is sometimes used to describe decreasing testosterone levels related to aging. Female menopause and so-called male menopause are two different situations, however.

In women, ovulation ends and hormone production plummets during a relatively short period of time. In men, production of testosterone and other hormones declines over a period of many years and the consequences aren't necessarily clear.

So what's the best way to refer to so-called male menopause? Many doctors use the term "andropause" to describe aging-related hormone changes in men. Other terms include testosterone deficiency syndrome, androgen deficiency of the aging male and late-onset male hypogonadism.

Understanding male hormones over time

Testosterone levels vary greatly among men. In general, older men tend to have lower testosterone levels than do younger men. Testosterone levels gradually decline throughout adulthood - about 1 percent a year after age 30 on average.

Recognizing low testosterone levels

A blood test is the only way to diagnose a low or reduced testosterone level. Some men have a lower than normal testosterone level without signs or symptoms. In this case, no treatment is needed.

Recognizable signs and symptoms of low testosterone levels may include:

Changes in sexual function. This might include reduced sexual desire, erectile dysfunction, fewer spontaneous erections - such as during sleep - and infertility. Your testes might become smaller as well.

Changes in sleep patterns. Sometimes low testosterone causes sleep disturbances, such as insomnia, or increased sleepiness.

Physical changes. Various physical changes are possible, including increased body fat, reduced muscle bulk and strength, and decreased bone density. Swollen or tender breasts (gynecomastia) and loss of body hair are possible. Rarely, you might experience hot flashes and have less energy.

Emotional changes. Low testosterone might contribute to a decrease in motivation or self-confidence. You might feel sad or depressed, or have trouble concentrating or remembering things.

Some of these signs and symptoms can be caused by underlying factors other than low testosterone, including medication side effects, thyroid problems, depression and excessive alcohol use. There also are conditions such as obstructive sleep apnea that might affect testosterone levels. Once these conditions are identified and treated, testosterone typically will return to a normal level.

Feeling your best

If you are experiencing signs and symptoms that might be the result of a low testosterone level, consult your doctor. He or she can evaluate possible causes for the way you feel and explain treatment options.

You can't boost your natural testosterone production, but these steps might help:

Be honest with your doctor. Work with your doctor to identify and treat any health issues that might be causing or contributing to your signs and symptoms - from medication side effects to erectile dysfunction and other sexual issues.

Make healthy lifestyle choices. Eat a healthy diet and include physical activity in your daily routine. Healthy lifestyle choices will help you maintain your strength, energy and lean muscle mass. Regular physical activity can even improve your mood and promote better sleep.

Seek help if you feel down. Men don't always experience depression as feelings of sadness. You may be unusually tired, anxious or irritable - even angry - and you may have trouble keeping up with your responsibilities at work and home. Other common symptoms in men include difficulty sleeping and thoughts of suicide. Talk with your doctor if you think you might be depressed. Many effective treatments are available.

Be wary of herbal supplements. Herbal supplements haven't been proved safe and effective for aging-related low testosterone. Some supplements might even be dangerous. Long-term use of DHEA, for example, has no proven benefits and might increase the risk of prostate cancer.

Treating aging-related low testosterone with testosterone replacement therapy is controversial.

For some men, testosterone therapy relieves bothersome signs and symptoms of testosterone deficiency. For others, the benefits aren't clear and there are possible risks.

Among the risks, testosterone therapy contributes to sleep apnea, stimulates noncancerous growth of the prostate and stimulates growth of existing prostate cancer. Testosterone therapy may also increase the risk of heart attack and stroke and contributes to the formation of blood clots in the veins.

If you wonder whether testosterone replacement might be right for you, work with your doctor to determine why your testosterone level is low and whether it is causing your symptoms. Weigh the pros and cons of treatment together with your doctor.

See more In-depth

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Aging-related hormone changes in men - sometimes called male menopause - are different from those in women. Understand signs, symptoms and treatment options. By Mayo Clinic Staff Hormone changes are a natural part of aging. Unlike the more dramatic reproductive hormone plunge that occurs in women during menopause, however, sex hormone changes in men occur gradually.

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Women may not be the only ones who suffer the effects of changing hormones. Some doctors are noticing that men are reporting some of the same symptoms that women experience in perimenopause and menopause.

The medical community is debating whether or not men really do go through a well-defined menopause. Doctors say that men receiving hormone therapy with testosterone have reported relief of some of the symptoms associated with so-called male menopause.

Because men do not go through a well-defined period referred to as menopause, some doctors refer to this problem as androgen (testosterone) decline in the aging male -- or what some people call low testosterone. Men do experience a decline in the production of the male hormone testosterone with aging, but this also occurs with conditions such as diabetes.

Along with the decline in testosterone, some men experience symptoms that include:

The relationship of these symptoms to decreased testosterone levels is still controversial.

Unlike menopause in women, when hormone production stops completely, testosterone decline in men is a slower process. The testes, unlike the ovaries, do not run out of the substance it needs to make testosterone. A healthy man may be able to make sperm well into his 80s or later.

However, as a result of disease, subtle changes in the function of the testes may occur as early as age 45 to 50 and more dramatically after the age of 70 in some men.

To make the diagnosis of male menopause, the doctor will:

Perform a physical exam

Ask about symptoms

Order tests to rule out medical problems that may be contributing to the condition

Order blood tests, which may include measuring testosterone level

If testosterone levels are low, testosterone replacement therapy may help relieve symptoms such as:

Just as with hormone replacement therapy in women, testosterone replacement therapy has potential risks and side effects. Replacing testosterone may worsen prostate cancer, for example.

If you are considering androgen replacement therapy, talk to a doctor to learn more. Your doctor may also recommend certain lifestyle or other changes to help with some symptoms of male menopause. These include:

Sources

MSNBC: "Male Menopause Out of the Closet."

WebMD Feature: "Menopause: Not Just For Women."

Mayo Foundation for Medical Education and Research: "Male menopause: Myth or reality?"

womenshealth.gov: "Aging Male Syndrome."

Mayo Foundation for Medical Education and Research: "Testosterone therapy: Can it help older men feel young again."

MedlinePlus Medical Encyclopedia: "Aging changes in the male reproductive system."

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Women may not be the only ones who suffer the effects of changing hormones. Some doctors are noticing that men are reporting some of the same symptoms that women experience in perimenopause and menopause. The medical community is debating whether or not men really do go through a well-defined menopause.

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Overview

Postmenopausal atrophic vaginitis, or vaginal atrophy, is the thinning of the walls of the vagina caused by decreased estrogen levels. This most commonly occurs after menopause.

Menopause is the time in a woman's life, usually between ages 45 and 55, when her ovaries no longer release eggs. She also stops having menstrual periods. A woman is postmenopausal when she has not had a period for 12 months or longer.

Women with vaginal atrophy have a greater chance of chronic vaginal infections and urinary function problems. It can also make sexual intercourse painful.

According to the American Association of Family Physicians, up to 40 percent of postmenopausal women have symptoms of atrophic vaginitis.

Symptoms

Symptoms of vaginal atrophy

While vaginal atrophy is common, only 20 to 25 percent of symptomatic women seek medical attention from their doctor.

In some women, symptoms occur during perimenopause, or the years leading up to menopause. In other women, symptoms may not appear until years later, if ever.

Symptoms can include:

thinning of the vaginal walls

shortening and tightening of the vaginal canal

lack of vaginal moisture (vaginal dryness)

vaginal burning (inflammation)

spotting after intercourse

discomfort or pain during intercourse

pain or burning with urination

more frequent urinary tract infections

urinary incontinence (involuntary leakage)

Causes

Causes of vaginal atrophy

The cause of atrophic vaginitis is a decline in estrogen. Without estrogen, vaginal tissue thins and dries out. It becomes less elastic, more fragile, and more easily injured.

A decline in estrogen can occur at other times besides menopause, including:

during breastfeeding

after removal of ovaries (surgical menopause)

after chemotherapy for treatment of cancer

after pelvic radiation therapy for treatment of cancer

after hormonal therapy for treatment of breast cancer

Regular sexual activity helps keep vaginal tissues healthy. A healthy sex life also benefits the circulatory system and improves heart health.

Risk factors

Risk factors for vaginal atrophy

Some women are more likely than others to get atrophic vaginitis. Women who have never given birth vaginally are more prone to vaginal atrophy than women who delivered their babies vaginally.

Smoking impairs blood circulation, depriving the vagina and other tissues of oxygen. Tissue thinning occurs where blood flow is decreased or restricted. Smokers are also less responsive to estrogen therapy in pill form.

Complications

Potential complications

Atrophic vaginitis increases a woman's risk of contracting vaginal infections. Atrophy causes changes in the acidic environment of the vagina, making it easier for bacteria, yeast, and other organisms to thrive.

It also increases the risk of urinary system atrophy (genitourinary atrophy). Symptoms associated with atrophy-related urinary tract problems include more frequent or more urgent urination or a burning sensation during urination.

Some women may also have incontinence and get more urinary tract infections.

Diagnosis

Diagnosing vaginal atrophy

See your doctor right away if sexual intercourse is painful, even with lubrication. You should also see your doctor if you experience unusual vaginal bleeding, discharge, burning, or soreness.

Some women are embarrassed to talk to their doctor about this intimate problem. If you're experiencing these symptoms, it's important to seek the advice of a doctor to help avoid the potential complications mentioned above.

Your doctor will ask you questions about your health history. They'll want to know how long ago you stopped having periods and whether you have ever had cancer. The doctor may ask what, if any, commercial or over-the-counter products you use. Some perfumes, soaps, bath products, deodorants, lubricants, and spermicides can aggravate the sensitive sexual organs.

Your doctor may refer you to a gynecologist for tests and a physical examination. During a pelvic exam, they will palpate, or feel, your pelvic organs. The doctor will also examine your external genitalia for physical signs of atrophy, such as:

pale, smooth, shiny vaginal lining

loss of elasticity

sparse pubic hair

smooth, thin external genitalia

stretching of uterine support tissue

pelvic organ prolapse (bulges in the walls of the vagina)

The doctor might order the following tests:

The smear test is a microscopic examination of tissue that has been scraped from the vaginal walls. It looks for certain types of cells and bacteria that are more prevalent with vaginal atrophy.

To test acidity, a paper indicator strip is inserted into the vagina. Your doctor can also collect vaginal secretions for this test.

You may also be asked to provide samples of blood and urine for laboratory testing and analysis. These tests check several factors, including your estrogen levels.

Treatment

Treatment of vaginal atrophy

With treatment, it's possible to improve your vaginal health and your quality of life. Treatment can focus on symptoms or the underlying cause.

Over-the-counter moisturizers or water-based lubricants can help treat dryness.

If symptoms are severe, your doctor may recommend estrogen replacement therapy. Estrogen improves vaginal elasticity and natural moisture. It usually works in just a few weeks. Estrogen can be taken either topically or orally.

Topical estrogen

Taking estrogen through the skin limits how much estrogen gets into the bloodstream. Topical estrogens don't treat any systemic symptoms of menopause, such as hot flashes. These types of estrogen treatments have not been shown to increase the risk of endometrial cancer. However, call your doctor right away if you're using topical estrogen and experience unusual vaginal bleeding.

Topical estrogen is available in several forms:

A vaginal estrogen ring, such as Estring. Estring is a flexible, soft ring inserted into the upper part of the vagina by you or your doctor. It releases a constant dose of estrogen and only needs to be replaced every three months. Estrogen rings are higher-dose estrogen preparations and may increase a woman's risk for endometrial cancer. You should speak with your physician about your risk and possible need for progestin as well.

A vaginal estrogen cream, such as Premarin or Estrace. These types of medications are inserted into the vagina with an applicator at bedtime. Your doctor may prescribe the cream daily for a couple of weeks, then step down to two or three times per week.

A vaginal estrogen tablet, such as Vagifem, is inserted into the vagina using a disposable applicator. Usually, one dose per day is prescribed at first, which is later stepped down to one or two times per week.

Learn more: Hormone therapy drugs: Estradiol vs. Premarin "
Oral estrogen

During menopause, oral estrogen is often used to treat hot flashes and vaginal dryness. But prolonged use heightens the risk of certain cancers. Oral estrogen usually isn't prescribed to people who have had cancer.

If your health history doesn't include cancer, progesterone may be prescribed in addition to estrogen in pill or patch form. Your doctor will work with you to decide which option is best for you.

Women taking progesterone and estrogen may have some bleeding after menopause. While the cancer risk for women taking both progesterone and estrogen is minimal, you should still see your doctor to have any episodes of postmenopausal bleeding evaluated. This can be an early sign of endometrial cancer.

Prevention

Prevention and lifestyle

In addition to taking medication, you can make certain lifestyle changes as well.

Wearing cotton underwear and loose-fitting clothing can improve symptoms. Loose cotton clothing improves air circulation around the genitals, making them a less ideal environment for bacteria to grow.

A woman with atrophic vaginitis can experience pain during sexual intercourse. However, staying sexually active enhances blood circulation in the vagina and stimulates natural moisture. Sexual activity has no effect on estrogen levels. But by improving blood circulation, it keeps your sexual organs healthier for longer. Allowing time to become sexually aroused can make sexual intercourse more comfortable.

Vitamin E oil can also be used as a lubricant. There's also some evidence that vitamin D increases moisture in the vagina. Vitamin D also helps the body absorb calcium. This helps to slow or prevent postmenopausal bone loss, especially when combined with regular exercise.
Read more: Natural treatments for vaginal atrophy "

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Postmenopausal atrophic vaginitis, or vaginal atrophy, is the thinning of the walls of the vagina caused by decreased estrogen levels. This most commonly occurs after menopause. Menopause is the time in a woman's life, usually between ages 45 and 55, when her ovaries no longer release eggs. She also stops having menstrual periods.

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Male menopause" is the more common term for andropause. It describes age-related changes in male hormone levels. The same group of symptoms is also known as testosterone deficiency, androgen deficiency, and late-onset hypogonadism.

Male menopause involves a drop in testosterone production in men who are age 50 or older. It's often affiliated with hypogonadism. Both conditions involve lowered testosterone levels and similar symptoms.

If you're a man, testosterone is a hormone produced in your testes. It does more than fuel your sex drive. It also fuels changes during puberty, fuels your mental and physical energy, maintains your muscle mass, regulates your fight-or-flight response, and regulates other key evolutionary features.

Male menopause differs from female menopause in several ways. For one thing, not all men experience it. For another, it doesn't involve a complete shutdown of your reproductive organs. However, sexual complications may arise as a result of your lowered hormone levels.

Symptoms

Male menopause can cause physical, sexual, and psychological problems. They typically worsen as you get older. They can include:

low energy

depression or sadness

decreased motivation

lowered self-confidence

difficulty concentrating

insomnia or difficulty sleeping

increased body fat

reduced muscle mass and feelings of physical weakness

gynecomastia, or development of breasts

decreased bone density

erectile dysfunction

reduced libido

infertility

You may also experience swollen or tender breasts, decreased testicle size, loss of body hair, or hot flashes. Low levels of testosterone associated with male menopause have also been linked to osteoporosis. This is a condition where your bones become weak and brittle. These are rare symptoms. They typically affect men at the same age as women entering menopause.

Cause

Before you hit puberty, your testosterone levels are low. Then they increase as you sexually mature. Testosterone is the hormone that fuels typical changes involved in male puberty, such as:

growth of your muscle mass

growth of your body hair

lowering of your voice

changes in your sexual functioning.

As you age, your testosterone levels will typically begin to drop. According to the Mayo Clinic, testosterone levels tend to decline an average of 1 percent per year after men turn 30. Some health conditions can cause earlier or more drastic declines in your testosterone levels.

Diagnosis and Treatment

Your doctor can take a sample of your blood to test your testosterone levels.

Unless male menopause is causing you severe hardship or disrupting your life, you'll probably manage your symptoms without treatment. The biggest hurdle in treating male menopause may be talking to your doctor about your symptoms. Many men are too intimidated or shy to discuss sexual topics with their doctors.

The most common type of treatment for symptoms of male menopause is making healthier lifestyle choices. For example, your doctor might advise you to:

eat a healthy diet

get regular exercise

get enough sleep

reduce your stress

These lifestyle habits can benefit all men. After adopting these habits, men who are experiencing symptoms of male menopause may see a dramatic change in their overall health.

If you're experiencing depression, your doctor may prescribe antidepressants, therapy, and lifestyle changes.

Hormone replacement therapy is another treatment option. However, it's very controversial. Like performance-enhancing steroids, synthetic testosterone can have damaging side effects. For example, if you have prostate cancer, it may cause your cancer cells to grow. If your doctor suggests hormone replacement therapy, weigh all of the positives and negatives before making your decision.

Outlook

It's normal to experience a decline in your testosterone levels as you get older. For many men, the symptoms are manageable, even without treatment. If your symptoms are causing you hardship, speak to your doctor. They can provide recommendations to help you manage or treat your symptoms.

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Male menopause" is the more common term for andropause. It describes age-related changes in male hormone levels. The same group of symptoms is also known as testosterone deficiency, androgen deficiency, and late-onset hypogonadism. Male menopause involves a drop in testosterone production in men who are age 50 or older.

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the comprehensive multidisciplinary study of aging and older adults; the scientific study of old age and of the process of becoming old... See the full definition

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Credit: Patrick Breig | Dreamstime

Question: My husband told me he has no energy to do chores around the house because he's suffering from male menopause. He's a very funny guy.

Answer: Your husband was obviously trying to yank your chain, but there's some truth in his joking. Fatigue is a common symptom of male menopause, also known as andropause (andro means male).

Both andropause and male menopause are used to describe decreasing levels of the male hormone testosterone that come with aging. Most men see testosterone levels drop as they get older. Some have described andropause as puberty in reverse.

Age-related decline in testosterone levels is also called testosterone deficiency, androgen decline in the aging male (ADAM) or late onset hypogonadism (LOH).

Andropause is different from the menopause women experience. In menopause, the production of female hormone drops suddenly. In men, there's a gradual decline in hormone levels.

When men reach about 40, testosterone levels usually begin to drop about one percent a year. The reduction is rarely noticeable in men younger than 60. By the time men reach their 80s, about half have low testosterone.

Young men often have testosterone levels exceeding 1000 nanograms per deciliter (ng/dl). The average testosterone level in 80 year-old men is 200 ng/dl.

Some men maintain normal testosterone levels into old age. And there are men with low testosterone levels who have no symptoms. The only sure way to learn if you are low on testosterone is by taking a blood test.

The following are some symptoms of low testosterone: diminished sex drive, reduced muscle bulk and strength, night sweats, infertility, fewer spontaneous erections, depression, loss of body hair, swollen breasts, palpitations, shrunken testes, height loss, fatigue, irritability, reduced self-confidence, poor concentration, memory loss, sleep problems, increased body fat and anemia.

It is normal for erections to occur less frequently in older men than in younger men.

However, erectile dysfunction (ED) is usually brought on by medical or psychological causes, not simple aging. About 90 percent of ED is believed have medical origins such as drugs taken to treat high blood pressure.

Here are some recommendations to deal with andropause:

See your doctor for a check-up. Discuss symptoms, medications you are taking, treatment options and lifestyle changes.

Many older men suffer from undiagnosed depression. Depression in men can be more than feeling down. Depressed men can be irritable and withdrawn. They often work too much, drink to excess and try to get thrills from taking risks. If you think you might be depressed, get help.

Regular exercise helps physically, mentally and emotionally.

Eat a healthy diet.

Testosterone replacement therapy (TRT) is the primary treatment for declining levels of testosterone, but it is enveloped in controversy. It has helped some men, but TRT has risks, especially for men with prostate cancer and heart disease. And, TRT may not improve symptoms. More studies need to be done to determine the safety and efficacy of TRT.

There are claims that herbal supplements can relieve symptoms. Not one of these supplements has been proven to be safe and effective for age-related low testosterone.

If you would like to read more columns, you can order a copy of "How to be a Healthy Geezer" at www.healthygeezer.com .

All rights reserved © 2011 by Fred Cicetti

More from the Healthy Geezer:

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Question: My husband told me he has no energy to do chores around the house because he's suffering from male menopause. He's a very funny guy. Answer: Your husband was obviously trying to yank your chain, but there's some truth in his joking.

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A Practical Solution for Dyspareunia in Breast Cancer Survivors: A Randomized Controlled Trial

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A Practical Solution for Dyspareunia in Breast Cancer Survivors: A Randomized Controlled Trial

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"In all, 46 patients, screened to exclude those with pelvic muscle and organ pain, uniformly had clinical evidence of severe vulvovaginal atrophy, dyspareunia (median pain score, 8 of 10; interquartile range [IQR], 7 to 9), increased sexual distress scores (median, 30.5; IQR, 23 to 37; abnormal, > 11), and abnormal sexual function"

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UW medicine Division of Gerontology Geriatric Medicine

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UW medicine Division of Gerontology Geriatric Medicine

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The University of Washington Gerontology and Geriatric Medicine provide comprehensive clinical care and training in the care of older adults throughout the University of Washington network

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Proposed working definition of an older person in Africa for the MDS Project

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Proposed working definition of an older person in Africa for the MDS Project

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Proposed working definition of an older person in Africa for the MDS Project

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The MDS Project collaborators agreed at the 2000 Harare MDS Workshop to use the chronological age of 60 years as a guide for the working definition of "old"; however, this definition was revisited during this meeting. Many felt this definition was not taking into account the real situation of older persons in developing countries, specifically in sub-Saharan Africa.

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[The elderly patient--who is that?]. - PubMed - NCBI

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When exactly does someone become elderly?

A recent New York Times story calls a 69-year-old woman elderly. Philadelphia Metro considers 70 to be elderly. When NPR ran a story recently about a 71-year-old midwife, some readers objected to the word "elderly" in the original headline.

One commenter responded: "REALLY?!? 'ELDERLY MIDWIFE'?! She's 71 and delivering babies! There's nothing elderly about her, and these days, not even her age!"

Another wrote: "I was 70 in Feb and I certainly do not feel elderly ... Elderly is at least over 80 and as someone else suggested maybe 95."

Editors decided to change the headline. And eventually, NPR's ombudsman weighed in on the "elderly" issue.

In the same way other words have morphed in widespread acceptability - handicapped to disabled; Oriental to Asian; retarded to mentally challenged, and even those words are still in flux - elderly is becoming politically (and politely) incorrect. Certain terms apparently have term limits.
Past Middle Age
"Nobody likes to think of themselves as old, let alone very old," says Michael Vuolo, co-host of Slate's Lexicon Valley podcast. " 'Elderly' often carries the connotation of feeble and dependent. Which is offensive if you're not and condescendingly euphemistic if you are."

The objection he has observed most often with regard to the phrase "the elderly," Vuolo says, "is similar to that of 'the deaf' or 'the disabled.' A construction like that creates a category without acknowledging that the category is composed of individuals. In other words, it's impersonal and other-ing. It's a bit like saying 'those people.' "

Just how old is elderly? "Rather old," according to Merriam-Webster, who doesn't really help matters. "Being past middle age."

Elderly is an old adjective dating back hundreds of years. It comes from an even older noun, elder, which the Oxford English Dictionary traces to the 10th century and defines as "in a wider sense, a predecessor, one who lived in former days."

In many circles, the word "elder" is a vaunted title of veneration. We are told to respect our elders. We look up to elder statesmen. We bow down before tribal elders.

To this day, certain religious groups, such as Presbyterians, elect "elders" to lead their congregations. Church elders can be young; they can be male or female. Similarly, many cities are run by aldermen - the British way of saying elder men. Aldermen can also be various ages and genders.
Where Earth Meets Sky
The word was not always so objectionable. In early 20th century America, "elderly" was socially preferable to the word "old."

"We like your use of the word elderly," observed Atlanta Constitution advice columnist Dr. William Brady in 1918. "Maybe we would have more friends now if we had not insisted upon anything old when we meant elderly."

But by 1956, some Americans were bristling at the description. When a 20-year-old girl referred to a 40-year-old man as "elderly" in a Washington Post story,readers reacted. The paper published the executive editor's advice to his staff about usage of the word. "A lot of us old folks in our 50s do not like to be called elderly," the editor opined. "When you are a great deal older than you are now, you will discover that the time a man becomes elderly is exactly like the place where the earth and sky meet."

He added, "When you are 16 you wonder how an old man of 30 manages to drag himself around. When you get to be 30 you feel that 60 is as old as Methuselah. When you get to be 60 you will think that the 'aged' are those in their 90s."

Now, 57 years later, the Washington Post is still wrestling with the question. A recent headline referred to a 68-year-old man as "elderly." Readers reacted.

"I hardly consider it apt," one letter-to-the-editor writer observed.

"What's wrong with being 'elderly'?" countered another reader. "Our society will forgo our fetish with youth only when we learn to embrace our age and the many descriptions of it, including 'mature,' 'well-seasoned' and 'elderly.' "
As Old As You Feel
The national longing for longevity is reaching new levels. Researchers tell us that 90 is the new 50. More and more products are created to make older people look and feel like younger people. And so the Elderly Line continues to shift, mirage-like, in the desert sand.

The wisest American elders may never agree on who is elderly and who is not. In Rhode Island public agencies, elderly officially begins at 60. In Hawaii, it arrives at 55. On a national note, the IRS Tax Counseling for the Elderly program offers free tax advice to anyone 60 or older.

In the end, "elderly" may be more a state of being - or feeling - than a certain age. And the question may not be whether someone else thinks of you as elderly, but whether you think of yourself as elderly.

Jon Carroll, a columnist for the San Francisco Chronicle, has been referring to himself as an "elderly man" for 20 years or so. "Sometimes I feel more elderly than others," says Carroll, who is 69. "I don't flinch anymore at 'elderly' or 'old'; I flinch more at euphemisms like 'senior citizen' or 'golden years.' "

He believes that it's important for older people "to take back the words for 'old' - another good word - and take the sting out of them. It's OK to be old."

And, at the same time, it is worthwhile and sobering to remember that, tragically, many people never even get the opportunity to grow old.

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When exactly does someone become elderly? A recent New York Times story calls a 69-year-old woman elderly. Philadelphia Metro considers 70 to be elderly. When NPR ran a story recently about a 71-year-old midwife, some readers objected to the word "elderly" in the original headline. One commenter responded: "REALLY?!? 'ELDERLY MIDWIFE'?!

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If age is indeed a number, where do Americans draw the line between middle-aged and elderly?

To people age 45 and younger, the line of demarcation for "old or middle-aged" is 61, according to a recent survey of more than 1,000 U.S. adults by The Marist College Institute for Public Opinion. Not surprisingly, people who find themselves on the far side of age 61 "tend to see it [as] young."

These findings echo those of a survey by the Pew Research Center , which concluded that older people felt younger than their chronological age, while younger people defined "old" as much younger than did older survey respondents.

A traditional means of assessing when one has chronologically surpassed middle age is Social Security collection, which for many years began at age 65, though now those born after 1959 must wait until is age 67 for full benefits. This controversial change was intended to reflect the fact that Americans are living longer, among other demographic changes -- so the definition of "old" is perhaps determined by life expectancy, and thus ever in flux. (And despite the longevity revolution, lots of boomers have started receiving Social Security benefits -- 63 percent of 65-year-olds, according to a recent MetLife study.)

Another traditional source of an old-age definition has been the time-honored senior citizen discount, though this isn't clear cut either: the Chicago Sun-Times reports that McDonalds is willing to classify customers looking for a discount as senior if they are 50, 55, 60 (depending on who you ask), or simply if they "look it." So not only is the cut-off vague, but appearance can outweigh birthdate as the determining factor, at least in face-to-face social interactions involving burgers and fries.

Perhaps the solution is to skip the labels entirely. In April the Spokesman-Review asked readers to pick a new name for the baby boomers -- and called the effort a "failed search" after receiving an overwhelming variety of responses. They included a spectrum of agedness (young-old versus old-old versus oldest-old) and various labels -- "New Agers," "Respected Elders," and "Generation Botox," reflecting the particular character of a generation that has been so keen to define itself as distinct. Age is indeed a slippery concept to define, and is perhaps best left in the eye of the beholder, or better yet, the beheld.

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If age is indeed a number, where do Americans draw the line between middle-aged and elderly? To people age 45 and younger, the line of demarcation for "old or middle-aged" is 61, according to a recent survey of more than 1,000 U.S. adults by The Marist College Institute for Public Opinion.

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Abstract

Objectives The aim of the European REVIVE survey was to achieve a better understanding of vulvovaginal atrophy (VVA), a chronic and progressive condition after menopause. We investigated perceptions, experiences and needs in terms of sexual and vaginal health in a sample of European postmenopausal women.

Methods An online internet based survey was conducted in Italy, Germany, Spain and the UK with a total surveyed sample of 3768 postmenopausal women (age: 45-75 years).

Results The most common VVA symptom was vaginal dryness (70%). VVA has a significant impact on the ability to be intimate (62%), to enjoy sexual intercourse (72%) and to feel sexual spontaneity (66%). Postmenopausal women with VVA are sexually active (51%), but their sexual drive is reduced. Health-care professionals (HCPs) have discussed VVA with postmenopausal women (62%), but they initiated the conversation only in 10% of the cases. The most common treatments for VVA are over-the-counter, non-hormonal, local vaginal products. Thirty-two per cent of postmenopausal women were naïve to any kind of treatment, whereas discussion with the HCP was relevant to be on current treatment (60% of postmenopausal women that discussed VVA with a HCP vs. 23% who did not). The top reasons for poor compliance with vaginal treatments were: not bothersome enough symptoms (18%); vaginal changes not therapeutically reversed (18%); relief from VVA symptoms (17%). Approximately 45% were satisfied with treatment. The most frequent disliked aspects of treatment were the route of administration or the messiness. The fear of hormones was common in postmenopausal women using vaginal prescription products.

Conclusions The European REVIVE survey confirmed that VVA symptoms are frequent in postmenopausal women and demonstrates a significant impact on quality of life and sexual life. However, the condition is still under-diagnosed and under-treated, with a high rate of dissatisfaction for actual available treatments in the four European countries surveyed. The discussion of symptoms with HCPs seems the most critical factor for diagnosis and treatment of VVA.

KEYWORDS: Vulvar and vaginal atrophy, postmenopausal women, REVIVE Survey, Europe, sexual relationships, vaginal dryness, dyspareunia, treatment

Introduction

Vulvar and vaginal atrophy (VVA) is a relatively common condition symptomatically affecting approximately 50% of all postmenopausal women. It is a consequence of reduced estrogenization of urogenital and pelvic tissue that results in a loss of vaginal elasticity, dryness, decreased lubrication, with associated irritation, dyspareunia, and urinary symptoms 1-6. Previous research has shown that the impact of VVA symptomatology in European women is significant, especially in those achieving their last menopause period, and this is a direct consequence of an aging population 7.

The disparity between the high prevalence and infrequent clinical diagnosis is documented in medical practice despite the considerable negative impact on quality of life 4,8. This inaccuracy is thought to be primarily a consequence of patients' unwillingness and/or embarrassment to report symptoms to their health-care professional (HCP) 9-11 and also, from a standpoint of the HCP, the difficulty of approaching this sensitive topic during routine consultations 12. Associated with this under-diagnosis is a chronic and progressive condition that may not be addressed for a considerable period of time, and therefore more likely to undergo disease progression when left untreated 13.

Currently available therapeutic options consist of topical over-the-counter (OTC) products (including non-hormonal moisturizers and lubricants applied in the vagina), prescribed systemic hormonal treatment (indicated when other menopausal symptomatology is also present), and prescribed local vaginal estrogen treatments (e.g. creams, suppositories, rings, and tablets) 3. In addition to the difficulty of achieving an early diagnosis, the most important issues that may compromise patients' adherence and therapeutic efficacy are the concerns, expressed by both women and HCPs, regarding the long-term safety of using estrogen-containing products and the convenience of topical product application 14,15.

During the last decade, many cross-cultural studies, predominantly surveys, have been conducted on postmenopausal women to gain new insight into the impact of VVA in current postmenopausal populations from different geographic distributions 8,12,16-20. These studies indicated that VVA symptoms have a global negative effect on sexual health, satisfaction, and sexual behavior, despite accounting for confounding factors due to population heterogeneity and absence of objective criteria to document the real medical condition.

Nevertheless, the existence of clear fragmentary information on therapies provided to patients as well as a lack of exploration of women's knowledge of available treatments for VVA are evident. Some misconceptions, such as the negative perceptions of estrogen therapy, continue to jeopardize the optimization of VVA management and its effective treatment 4,21.

The objective of the present REVIVE-EU (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs-Europe) survey was to characterize women's knowledge of VVA and its symptomatology in relation to menopause in four European countries, to describe the impact of VVA symptoms on women's daily life, and to understand current European attitudes to HCP interactions. This focus may help to gain both a better understanding of European menopausal women's perceptions, experiences, and needs in relation to sexual and vaginal health treatments, and to achieve a significant improvement in the efficacy and therapeutic adherence.

Methods

Population

The European REVIVE included a cohort of 3768 postmenopausal women with VVA symptoms from four European countries (1000 from Germany, 1000 from Italy, 1000 from the UK, and 768 from Spain). The inclusion criteria were as follows: menopausal (either natural or surgically induced) women, residence in one of the four study countries, aged between 45 and 75 years old, and who have experienced at least one of the vulvar and vaginal atrophy symptoms (dryness, pain with sex, irritation, tenderness, pain with exercise and/or bleeding).

REVIVE-EU

The European REVIVE (REVIVE-EU) survey is a translated and culturally adapted version of the previous USA REVIVE questionnaire (research agency: Eikon Europe; panel used: Toluna Group). The comprehensive online questionnaire was approved by the corresponding accredited institutional review board. The survey participants were appropriately informed of the nature of the study and gave informed consent to participate. Before the beginning of the study period, the online questionnaire was pre-tested on 5% of the UK sample (50 participants) to ensure participants fully understood the survey questions. The last European iteration of the survey lasted 35 min and was designed with a margin error of 3.1% at the 95% confidence interval. The invitation to participate was sent to the target population (postmenopausal women with at least one VVA symptom after the onset of menopause) by the panel (selected by age range), who were compensated with points that can then be redeemed for vouchers or gadgets (but not for products or money). Participants entered the secure online questionnaire portal and completed the survey between June 18, 2014 and July 22, 2014. Prior to the completion of the questionnaire, a three-step screening process was completed (see ). After the screening, the information collected from the participants included: level of knowledge about VVA and menopausal symptomatology, interactions with HCPs with respect to VVA symptomatology, impact of VVA symptoms on sexual and daily living activities, current or previous use of OTC products for VVA, current or previous use of prescription treatments for VVA, and attitudes toward VVA treatments.

Eligible patients were those who fulfilled all selection criteria and who had valid data for the variable/s considered. There was no imputation of missing data. Descriptive statistics were summarized by relative frequency distributions for categorical variables of the questionnaire.

Results

Survey population distribution

The baseline demographics and clinical characteristics of the final sample of 3768 survey participants are summarized in . For the age demographic, the 50-60-year age range was the most represented range in the sample (60.5%). Among the cohort of participants surveyed (), 1799 (47.7%) had experienced VVA symptoms in the past month and 2480 (65.8%) in the past 6 months, respectively. At the moment of starting the survey, 1703 (94.7%) of those with recent VVA symptoms were receiving VVA treatment.

VVA knowledge and menopause awareness

According to this cohort of postmenopausal European women, 39.9% of the participants were able to directly attribute VVA to the menopausal transition. By contrast, only 8.1% of participants responded that they were not aware of the cause of their VVA symptoms. Additionally, almost 47% of participants were not aware of the VVA condition. Within the cohort of participants that were aware of the VVA condition, this knowledge and information came through direct discussions with their HCP (44.0%), active internet searching (11.0%) or newspaper/journal paper reading (10.0%). In the total sample included, only 16.4% of the participants had been officially clinically diagnosed with VVA.

VVA symptoms and impact on sexual life and other activities

The most common VVA-associated symptoms in European postmenopausal women were vaginal dryness (70.0%), followed by vaginal irritation (32.7%), pain during intercourse (dyspareunia) (29.0%) and vaginal tenderness (14.3%). The retrospective report of the onset of symptoms associated or linked with VVA is presented in .

Most participants (65% or more) reported the onset of VVA symptoms during the postmenopausal period. The onset of symptoms varied considerably across menopause stages; vaginal irritation was the most likely symptom to occur before menopause (13.1%), while vaginal dryness, pain with exercise and tenderness were the most likely symptoms to begin within the first year after menstrual cessation (25.8%, 25.5% and 24.7%, respectively). The onset of pain with intercourse could occur across all the menopause and postmenopause period, but appears most commonly at the exact time of menopause (23.0%) or the subsequent year (23.0%).

Overall, VVA symptoms were reported to have the most impact on participants' sexual satisfaction (72.0% somewhat or very interfering), followed by interferences in sexual spontaneity (66.4%), intimacy (61.9%), and relationship with their partner (59.6%), respectively (). About 60% of the participants stated that symptoms were the same or worse now than when they first appeared, especially with regard to pain during intercourse (76.7%). All VVA symptoms were rated as quite bothersome, but pain and bleeding associated with sex rated as the most bothersome symptoms (51.8% and 45.0% of participants rated them as extremely bothersome). Participants also reported that VVA symptoms made them feel uncomfortable (47.7%), 'old' (39.9%), frustrated (17.6%) and/or unattractive (14.4%). When asked about what is the most concerning facet as a result of VVA symptoms, most participants felt losing their sexual intimacy (40.3%) and their youth (19.1%) were the most significant points of concern.

Participants with a partner (77.9%) were co-habitating in 84.5% of cases, 25.5% of which were without sexual activity in the last year. For participants who had sexual activity during the last year, the most important VVA symptoms were described as pain associated with intercourse (82.6%), vaginal and/or vulvar dryness (78.3%) and pelvic tenderness (67.1%). Overall, the survey shows that sexual drive was diminished in about 50% of patients as a direct result of VVA symptomatology.

Health-care professional relationship

Altogether, 88.8% of participants reported visiting a HCP for their gynecological needs; over half of these HCPs were female physicians (58.4%). Specifically, 2540 participants (67.4%) reported having a gynecologist/obstetrician for their main gynecological needs and 799 (21.2%) had a GP/family practitioner. Overall, 74.1% of the participants consulted their main HCP during the last 12 months. Among participants who reported having a HCP for their gynecological needs, only 10.5% indicated that their HCP usually asked about that participant's sexual activity during the routine physical examination. By contrast, 65.1% of participants acknowledged that they expect their HCP to initiate a conversation to inquire about menopause-related symptoms.

More than six out of ten participants in the survey (61.6%) had specifically discussed VVA symptoms with their HCP; however, only 10.3% of them said that the HCPs themselves had initiated the conversation. The most commonly reported reasons for avoiding a discussion with their HCP about VVA were beliefs that symptoms were a natural component of the aging process (42.6%), followed by the statement that symptoms were not bothersome enough to be considered problematic and did not warrant discussion with their HCP (26.0%). More than half of the participants (54.6%) had spoken to their partner about VVA symptomatology. Remarkably, depending on the specific symptom, between 36.0% (vaginal/vulvar irritation) and 50.0% (pain associated with sexual intercourse) of participants suffered VVA for more than 6 months before they initiated a discussion with a HCP. Satisfaction with how the HCP handled the first discussion about VVA symptoms was declared in 62.5% of cases.

Participants' experiences regarding VVA treatments

In the total European REVIVE survey, 1703 participants (45.2%) were currently using a VVA-specific treatment (OTC lubricants or moisturizers, prescribed local estrogens, other OTC medications, or herbal therapies), 32.1% were treatment-naïve and 22.7% had lapsed from their treatment schedule at the time of the survey (). Women who discussed VVA with a HCP were twice as likely to be current medication users (59.7% vs. 22.7% for those who had not discussed VVA). Within the group of participants under current treatment, 62.2% were using OTC products, compared to 13.9% using vaginal prescription therapies and 17.5% using both kinds of products. These participants initiated treatment for their VVA symptoms in different manners: 17.2% started treatment through a HCP prescription and the recommendation of an OTC product to be used together, another 16.0% began treatment through a HCP prescription without a OTC product recommendation, and another 15.8% started using an OTC product before talking to a HCP or before receiving a specific prescription.

An overall ratio of 39.2% of participants abandoned their treatment at some point, and justified it mainly because they did not consider their symptoms bothersome enough to continue treatment (18.4%), the medication was not able to reverse the vaginal changes (18.3%), the consolidated relief from vaginal/vulvar symptoms (17.5%), the price and high expense of the treatment (10.4%), and their assumption that symptoms would diminish with time (10.4%). In patients who completed their OTC treatment or who were currently taking it, 45.2% reported overall satisfaction; while 8.4% continued to be dissatisfied (46.4% had a neutral opinion). By contrast, in patients who completed their prescription medication or who were currently taking it, 44.3% showed a global satisfaction with it, while only 10.4% were dissatisfied (45.3% neutral).

The percentages of participants who were worried or concerned about the long-term use of VVA medication are summarized in . Participants using vaginal prescription products showed a higher degree of concern with long-term use and felt themselves less comfortable than those with OTC moisturizers or lubricants. The main worries expressed by the participants about the long-term use and safety of VVA medications were the concerns about side-effects (55.7%), followed by aspects related to hormone exposure and a possible predisposition for developing cancer (24.6%). The concerns about the unknown implications of long-term use (19.7%) were also mentioned by participants. Within the group of participants who experienced symptoms, but did not use medication, 5.0% claimed significant concerns/worry about breast cancer. On the contrary, in participants currently using treatment, breast cancer concerns tended to be lower (5.1% in those with prescription, 2.4% in those using an OTC moisturizer, and only 1.0% in those using OTC lubricants).

Survey participants also expressed their views on VVA treatment difficulties (). Users of OTC moisturizers were most worried about efficacy issues, such as the inability to restore the vagina to its natural state (27.8%) or the limitation on symptom relief (13.1%). They also had concerns related to the price of the product (14.2%) and its impact on sexual spontaneity (15.0%). Participants who used OTC vaginal lubricants were mainly worried by the limitations of the product in restoring the vagina to its natural state (28.2%) and the administration of the products, which were considered messy (18.5%). Almost 10% of these users also considered the product to be expensive. In terms of administration, 54.0% of participants who have a priority with route of administration showed a clear preference for an oral pill, whereas only 46.0% preferred or somewhat preferred a vaginally-administered product for the treatment of VVA problems. Participants who were taking prescription vaginal products for VVA symptoms had lower but still significant issues with the ability of the product to restore the natural state of the vagina (25.7%). They were also worried with safety issues like: long-term effect on safety (21.3%), hormone exposure (16.5%), vaginal discharge (15.0%), other side-effects (16.3%), as well as the possibility of estrogen absorption by their partner (3.9%).

Discussion

The European REVIVE was conducted in the largest cohort of postmenopausal women included in a survey of this nature to date. The survey of 3768 postmenopausal women with diagnosed VVA symptomatology included in the European version of the REVIVE study highlights the persistent and significant lack of awareness of the underlying pathology and its origin. Furthermore, this study has detected several limitations in clinical and therapeutic management of this chronic condition in the four European counties surveyed. For example, participants' main concerns about VVA symptoms were centered on interference with sexual behavior and loss of intimacy. These results follow a similar pattern to those observed previously (i.e. in the VIVA Survey, 64% had sexual intimacy interference and 32% had interference with the loving relationship with a partner) 8,12,17,18,21. This study clearly shows the important impact of VVA symptoms in European women after menopause, especially in aspects related to sexual satisfaction and spontaneity, with the ability to be intimate, and the ability to establish a trusted relationship with partners.

Almost four out of ten European participants with VVA symptoms were able to associate the symptoms with menopause as a causal factor, which implies a higher identification of VVA as a chronic menopause-linked syndrome than in previously published surveys 8,9,20. This difference could be, in part, related to a difference in the ability to access the resources necessary for a VVA diagnosis and differences between medical evaluation methodologies in Europe and in the United States. Additionally, it should be noted that the nomenclature of VVA has recently evolved to be part of the more extensive genitourinary syndrome of menopause (GSM) according to the recommendations of the International Vulvovaginal Atrophy Terminology Consensus Conference Panel, as a more accurate and all-encompassing term in order to improve and ease conversations between patients and their HCPs 22.

Although the majority of participants experienced one unique symptom associated with VVA, a very high proportion of patients experienced two or more symptoms before consultation with a HCP. This pattern is related with another observation concerning the waiting time before discuss their problems: between 36% and 50% of participants (depending on the observed symptoms) waited more than 6 months to discuss them with a HCP. This confirms that VVA is an under-recognized, under-diagnosed and undertreated condition among postmenopausal participants who, although experiencing bothersome symptomatology, quite often do not seek medical help 8,9,23,24. Vaginal dryness ranked first in the top symptoms to appear in postmenopause, being also the symptom which most participants clearly identified as being directly related to the menopause process 25.

Symptoms were usually reported as not being resolved over time or in fact worsening as time progressed, causing discomfort and impacting sexuality and the quality of life, even for participants who reported satisfaction with treatments. Pain during intercourse was the most bothersome symptom and was associated with a significant impact on healthy and satisfying intimate relations 26, which are a desired effect of the treatment stated by the surveyed participants. The study shows an unmet medical need which is related to poor public awareness and lack of education on VVA symptoms, terminology and the impact of the disease on the woman and her partner. Although more participants are able to associate their VVA symptomatology with menopause than previously reported 20, the majority are still unaware that the symptoms are due to a recognized and treatable medical condition, and that they are strongly compromising their ability to maintain an active and healthy level of sexual intimacy 27. Educational and public awareness campaigns are warranted.

Even though the discussion of symptoms with a HCP has a significant impact on the incidence of the diagnosis of VVA, an important conclusion of our study is the proven difficulty and inadequacy of fluent communication related to VVA symptoms between patients and HCPs. First, the majority of participants wait several months or years with active symptoms before speaking to a HCP and only 10% of HCPs initiate a discussion on VVA symptoms. Second, nearly 40% of participants had never discussed their symptoms with a HCP. Finally, only 16% of symptomatic participants received a formal VVA diagnosis by their HCP. These observations demonstrate the importance of an increased awareness and responsiveness of HCPs regarding VVA and its impact in postmenopausal women. A paucity of knowledge related to available treatments remains, although differential behaviors could be identified between primary-care clinicians and the obstetrics/gynecology specialists, with the latter group being more likely to routinely assess patients' sexual activities (63%) and sexual problems (40%) 8,9,28,29.

Within the main findings of the current European survey, one must highlight the low satisfaction and significant concerns expressed by symptomatic participants with VVA treatment (OTC and/or prescription medication), mainly justified by a skeptical view that available treatments can effectively reverse the vaginal changes and by safety and convenience limitations. The incidence of the OTC/prescription combination is low. Remarkably, one in three participants remained untreated, notwithstanding the fact that lubricants should be used as the first-line treatment to ease sexual intercourse according to the North American Menopause Society guidelines 30-32. In addition, 25% of treated participants discontinued their treatment, and close to 40% abandoned it completely. As a consequence, the role of HCPs appears important in two main therapeutic aspects: (1) the HCP must be more active in creating diverse educational awareness on how to deal with VVA symptoms; and (2) the HCP must facilitate discussions with their patients on menopause symptomatology and therapeutic needs associated with sexual health. Lastly, even if concerns regarding VVA prescription treatments, usually associated with safety issues of the estrogen therapy, are expressed by participants, the HCP must be well versed in the etiology of the condition (decrease in endogenous estrogen after the menopause) and that the benefits and efficacy of minimally absorbed local vaginal estrogen therapy in alleviating VVA symptoms have been extensively proven 31,33. Patient education and support may help in patient compliance with treatment. Furthermore, HCPs must be aware of the risk-benefit profile of the products that are available for the treatment of VVA and possible concerns of the patient should be addressed.

Some limitations of this survey are a consequence of the characteristics and nature of surveys. The data of the European REVIVE study came from a self-reported, on-line questionnaire, a type of questionnaire that suffers from a certain recall bias effect and is subject to respondent bias through the limitations of reporting subjective symptoms from an objective condition. Another limitation may be attributable to sociocultural and country-specific differences present in Europe. For example, participants were difficult to detect, the level of information that could be acquired was inconsistent, open-mindedness to discuss VVA symptomatology was variable, and therapeutic products differed in availability, amongst others. Cross-cultural variables were not addressed. Nevertheless, the sample included in the REVIVE study represents the largest cohort of European postmenopausal women interviewed on VVA symptomatology; therefore this may represent and reflect a 'real-world' perspective on the VVA condition and its therapeutic opportunities. The results may, in fact, be generalizable to the European population as a whole due to the diversity of the patients surveyed.

Conclusions

The European REVIVE study has highlighted the significant impact of VVA symptomatology in women living in four European countries. Direct HCP-patient communication and interaction still suffers from a considerable lack of dialogue that must be actively promoted from the professional point of view in order to convey updated and complete information about the VVA etiology and its progressive nature to patients. Proactivity by the HCP should be centered on educating the patients with updated information on VVA, its diagnosis, assessment and the risks/benefits of a suitable therapeutic approach.

The European REVIVE study leads to the conclusion that a well-developed educational program focusing on these issues will have a positive impact on the adherence to treatment and the overall therapeutic efficacy with direct impact on satisfaction and quality of life of European women suffering from VVA.

Acknowledgements

The authors would like to thank Emili González-Pérez (TFS Develop), Scientific Advisor and Medical Writer, for his assistance with manuscript preparation. Sponsorship and article processing charges for this study were funded by Shionogi, Inc.

Conflict of interest

Rossella E. Nappi had a financial relationship (lecturer, member of advisory boards and/or consultant) with Bayer HealthCare AG, Boehringer Ingelheim, Ely Lilly, Gedeon Richter, HRA Pharma, Merck Sharpe & Dohme, Novo Nordisk, Pfizer Inc, Procter & Gamble Co, Shionogi Limited and TEVA Women's Health Inc. Santiago Palacios has been a symposium speaker or advisory board member for Servier, Pfizer, GSK, Abbott, Ferrer, Bioiberica, Shionogi, Amgen, Novo Nordisk and Teva. He has also received research grants and/or consulting fees from Pfizer, Servier, Amgen, MSD, Preglem, Leon Farma, Gynea, Sandoz, Procare Health and Bayer. Nick Panay has received honoraria for lecturing and acting in an advisory capacity for a number of pharma companies including Abbott, Bayer, Besins, Novo Nordisk, Pfizer and Shionogi. Martire Particco is an employee of Shionogi Italy. Michael L. Krychman received financial support or consulting fees from Shionogi Inc, Pfizer, Palatin, Noven Therapeutics, Materna and Viveve Medical. He receives support for his speakers' bureau activities from Noven Therapeutics, Pfizer and Shionogi.

Source of funding

Financial support for the REVIVE Survey was provided by Shionogi Limited.

References

MacBride MB, Rhodes DJ, Shuster LT. Vulvovaginal atrophy. Mayo Clin Proc. 2010;85:87-94. [PMC free article]

2011 EU Census [Internet]. http://ec.europa.eu/eurostat/web/population-and-housing-census/census-data/2011-census

Parish SJ, Nappi RE, Krychman ML. [et alImpact of vulvovaginal health on postmenopausal women: a review of surveys on symptoms of vulvovaginal atrophy. Int J Womens Health 20135437-47. PMC free article]

REVEAL: REvealing Vaginal Effects At mid-Life. Surveys of postmenopausal women and health care professionals who treat postmenopausal women. Madison, NJ: Wyeth; 2009.

Shulman LP, Portman DJ, Lee WC. et alA retrospective managed care claims data analysis of medication adherence to vaginal estrogen therapy: implications for clinical practice. J Womens Health 200817569-78.

Pfizer Pharmaceuticals, Inc. www.personalmenopauseanswers.com/healthy-women-survey.aspx

News release from Novo Nordisk. 2012.

Simon J, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Proceedings of the North American Menopause Society (NAMS); Dallas, TX, USA: 2007.

Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. What we don't talk about when we don't talk about sex: results of a national survey of U.S. obstetrician/gynecologists. [PMC free article]

Kingsberg S, Kellogg S, Krychman M. Treating dyspareunia caused by vaginal atrophy: a review of treatment options using vaginal estrogen therapy. Int J Womens Health. 2010;1:105-11. [PMC free article]

Rees M, Pérez-López FR, Ceasu I. et alEMAS clinical guide: low-dose vaginal estrogens for postmenopausal vaginal atrophy. Maturitas 201273171-4.

# data[].attributes.attachment_link.title
Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey

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Objectives The aim of the European REVIVE survey was to achieve a better understanding of vulvovaginal atrophy (VVA), a chronic and progressive condition after menopause. We investigated perceptions, experiences and needs in terms of sexual and vaginal health in a sample of European postmenopausal women.

# data[].attributes.attachment_link.readable_text
The uterus, or womb, is a muscular structure that's held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they're no longer able to support the uterus, causing prolapse. Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina, or birth canal.

Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse describes a situation in which the uterus falls so far down that some tissue rests outside of the vagina.

Symptoms

Women who have a minor uterine prolapse may not have any symptoms. Moderate to severe prolapse may cause symptoms, such as:

feeling like you're sitting on a ball

vaginal bleeding

increased discharge

problems with sexual intercourse

seeing the uterus or cervix coming out of the vagina

a pulling or heavy feeling in the pelvis

constipation

recurrent bladder infections

If you develop these symptoms, it's important to see your doctor and get treatment right away. Without proper attention, the condition can impair your bowel, bladder, and sexual function.

Risk factors

The risk of having a prolapsed uterus increases as a woman ages and her estrogen levels decrease. Estrogen is the hormone that helps keep the pelvic muscles strong. Damages to pelvic muscles and tissues during pregnancy and childbirth may also lead to prolapse. Women who've had more than one vaginal birth and postmenopausal women are at the highest risk.

Any activity that puts pressure on the pelvic muscles can increase your risk of a uterine prolapse. Other factors that can increase your risk for the condition include:

obesity

chronic coughing

chronic constipation

Diagnosis

Your doctor can diagnose uterine prolapse by evaluating your symptoms and performing a pelvic exam. During this exam, your doctor will insert a device called a speculum that allows them to see inside of the vagina and examine the vaginal canal and uterus. You may be lying down, or your doctor may ask you to stand during this exam.

Your doctor may ask you to bear down as if you're having a bowel movement to determine the degree of prolapse.

Treatments

Treatment isn't always necessary for this condition. If prolapse is severe, talk with your doctor about which treatment option is appropriate for you.

Nonsurgical treatments include:

losing weight to take stress off of pelvic structures

avoiding heavy lifting

doing Kegel exercises, which are pelvic floor exercises that help strengthen the vaginal muscles

taking estrogen replacement therapy

wearing a pessary, which is a device inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix

Surgical treatments include uterine suspension or hysterectomy. During uterine suspension, your surgeon places the uterus back into its original position by reattaching pelvic ligaments or using surgical materials. During a hysterectomy, your surgeon removes the uterus from the body through the abdomen or the vagina.

Surgery is often effective, but it's not recommended for women who plan on having children in the future. Pregnancy and childbirth can put an immense strain on pelvic muscles, which can undo surgical repairs of the uterus.

Prevention

Uterine prolapse may not be preventable in every situation. However, you can do to things to reduce your risk, including:

getting regular physical exercise

maintaining a healthy weight

practicing Kegel exercises

using estrogen replacement therapy during menopause

# data[].attributes.attachment_link.description
The uterus, or womb, is a muscular structure that's held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they're no longer able to support the uterus, causing prolapse. Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina, or birth canal.

# data[].attributes.attachment_link.readable_text
Your uterus (or womb) is normally held in place inside your pelvis with various muscles, tissue, and ligaments. Because of pregnancy, childbirth or difficult labor and delivery, in some women these muscles weaken. Also, as a woman ages and with a natural loss of the hormone estrogen, her uterus can drop into the vaginal canal, causing the condition known as a prolapsed uterus.

Muscle weakness or relaxation may allow your uterus to sag or come completely out of your body in various stages:

First degree: The cervix drops into the vagina.

Second degree: The cervix drops to the level just inside the opening of the vagina.

Third degree: The cervix is outside the vagina.

Fourth degree: The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting muscles.

Other conditions are usually associated with prolapsed uterus. They weaken the muscles that hold the uterus in place:

Cystocele: A herniation (or bulging) of the upper front vaginal wall where a part of the bladder bulges into the vagina. This may lead to urinary frequency, urgency, retention, and incontinence (loss of urine).

Enterocele: The herniation of the upper rear vaginal wall where a small bowel portion bulges into the vagina. Standing leads to a pulling sensation and backache that is relieved when you lie down.

Rectocele: The herniation of the lower rear vaginal wall where the rectum bulges into the vagina. This makes bowel movements difficult, to the point that you may need to push on the inside of your vagina to empty your bowel.

The following conditions can cause a prolapsed uterus:

Pregnancy/childbirths with normal or complicated delivery through the vagina

Weakness in the pelvic muscles with advancing age

Weakening and loss of tissue tone after menopause and loss of natural estrogen

Conditions leading to increased pressure in the abdomen such as chronic cough (with bronchitis and asthma), straining (with constipation), pelvic tumors (rare), or an accumulation of fluid in the abdomen
Being overweight or obese with its additional strain on pelvic muscles

Major surgery in the pelvic area leading to loss of external support

Other risk factors include:

Continued

Symptoms of a prolapsed uterus include:

A feeling of fullness or pressure in your pelvis (you may describe it as a feeling of sitting on a small ball)

Low back pain

Feeling that something is coming out of your vagina

Painful sexual intercourse

Difficulty with urination or moving your bowels

Discomfort walking

Notify your health care provider if you experience any of the following symptoms:

You feel the cervix near the opening of the vaginal canal or you feel pressure in your vaginal canal and the feeling of something coming out of your vagina.

You suffer persistent discomfort from urinary dribbling or the urge to have a bowel movement (rectal urgency).

You have continuing low back pain with difficulty in walking, urinating, and moving your bowels.

Seek medical care immediately if you experience any of the following:

Obstruction or difficulty in urination and/or bowel movement

Complete uterine prolapse (your uterus comes out of your vagina)

Your health care provider can diagnose uterine prolapse with a medical history and physical examination of the pelvis.

The doctor may need to examine you in standing position and while you are lying down and ask you to cough or strain to increase the pressure in your abdomen.

Specific conditions, such as ureteral obstruction due to complete prolapse, may need an intravenous pyelogram (IVP) or renal sonography. Dye is injected into your vein, and a series of X-rays are taken to view its progress through your bladder.

Ultrasound may be used to rule out other pelvic problems. In this test, a wand is passed over your abdomen or inserted into your vagina to create images with sound waves.

Treatment depends on how weak the supporting structures around your uterus have become.

You can strengthen your pelvic muscles by performing Kegel exercises. You do these by tightening your pelvic muscles, as if trying to stop the flow of urine. This exercise strengthens the pelvic diaphragm and provides some support. Have your health care provider instruct you on the proper ways to isolate and exercise the muscles.

Continued

Estrogen (a hormone) cream or suppository ovules or rings inserted into the vagina help in restoring the strength and vitality of tissues in the vagina. But estrogen is only for use in select postmenopausal women.

Depending on your age and whether you wish to become pregnant, surgery can repair the uterus or remove it. When indicated, and in severe cases, your uterus can be removed with a hysterectomy. During the surgery, the surgeon can also correct the sagging of the vaginal walls, urethra, bladder, or rectum. The surgery may be performed by an open abdominal procedure, through the vagina, or through small incisions in the abdomen or vagina with specialized instruments.

If you do not want surgery or are a poor candidate for surgery, you may decide to wear a supportive device, called a pessary, in your vaginal canal to support the falling uterus. You can use this temporarily or permanently. They come in various shapes and sizes and must be fitted to you. If your prolapse is severe, a pessary may not work. Also, pessaries can be irritating inside your vagina and may cause a foul-smelling discharge.

Follow-up depends on how your condition was treated.

If you had surgery, you need to follow up according to your surgeon's advice.

If you have a pessary inserted in your vagina, it needs to be cleaned and checked by your health care provider for the correct position and fit at regular intervals unless you are instructed on how to remove it and clean it yourself at home.

If you have been told to do Kegel exercises, you should have a regular follow-up visit so that your health care provider can check the progress of your muscle strength.

Avoid constipation by eating a high-fiber diet.

Do Kegel exercises to strengthen your pelvic muscles.

Avoid heavy lifting or straining.

Pessaries can be effective temporarily or permanently if they are checked and cleaned as often as necessary. Surgery can support a prolapsed uterus or remove it.

WebMD Medical Reference Reviewed by Nivin Todd, MD on November 25, 2015

Sources

Authors and Editors

Author: Sarah Samreen, MBBS, Instructor, Department of Health Sciences, Ziauddin Medical University, Pakistan.

Coauthor(s): George Lazarou, MD, FACOG, Director, Urogynecology and Reconstructive Pelvic Surgery; Jack D. Weiler, MD, Montefiore Medical Center and assistant professor, Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine; Aneela Naureen Hussain, MD, MBBS, assistant professor, Department of Family Practice, State University of New York Downstate Medical Center; Suhaib Waqarul Haq, MBBS, Medical Officer, Department of Radiology, Abbasi Shaheed Hospital, Karachi, Pakistan.

Editors: Jeter (Jay) Pritchard Taylor III, MD, vice-chief/compliance officer Department of Emergency Medicine, Palmetto Richland Memorial Hospital, University of South Carolina; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Lee P. Shulman, MD, professor of Obstetrics and Gynecology, head, Section of Reproductive Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

# data[].attributes.attachment_link.description
Your uterus (or womb) is normally held in place inside your pelvis with various muscles, tissue, and ligaments. Because of pregnancy, childbirth or difficult labor and delivery, in some women these muscles weaken. Also, as a woman ages and with a natural loss of the hormone estrogen, her uterus can drop into the vaginal canal, causing the condition known as a prolapsed uterus.

# data[].attributes.attachment_link.readable_text
Abstract

Uterine prolapse is a condition that has likely affected women for all of time as it is documented in the oldest medical literature. By looking at the watershed moments in its recorded history we are able to appreciate the evolution of urogynecology and to gain perspective on the challenges faced by today's female pelvic medicine and reconstructive surgeons in their attempts to treat uterine and vaginal vault prolapse.

"He who cannot render an account to himself of at least three thousand years of time, will always grope in the darkness of inexperience"

-Goethe, Translation of Panebaker

1. Introduction

This special issue provides urogynecologists with the opportunity to explore recent advances that have and will continue to propel our subspecialty forward. Simultaneously, it provides us with the opportunity to look back and appreciate the landmark moments that have led us to our current state of affairs. It is with this spirit, mindful of Goethe's words, that this paper will focus its attention on a brief history of the management of uterine prolapse.

2. Antiquity to the Common Era

Uterine prolapse is an ailment that has seemingly affected women for all of time. In fact, the problem of uterine prolapse and its potential treatment is described in the oldest documented medical literature, the Egyptian Papyri, where it is written, "of a woman whose posterior, belly, and branching of her thighs are painful, say thou as to it, it is the falling of the womb," (Kahun papyrus ca. 1835 B.C.E.) [ 1]. The Ebers papyrus goes on to recommend "to correct a displaced womb: with oil of earth (petroleum) with fedder (manure) and honey; rub the body of the patient," (Ebers papyrus ca. 1550 B.C.E.) [ 2].

Over one thousand years later, during the time of Hippocrates (c. 460-377 B.C.E.) and the subsequent generations that he influenced, the prevailing medical thought was that the uterus acted as an animal unto itself. This concept led to treatments such as fumigation, in which pleasant fumes would be placed at a woman's head and vile ones near her prolapsed womb, in order to stimulate the uterus to retreat. Polybus, a pupil of Hippocrates (and his son-in-law), wrote in his noted text "On Diseases of Women," of other therapies for uterine prolapse including the application of an astringent to the womb followed by placement of a vinegar soaked sponge, or halved pomegranate. If these measures failed, women were subjected to succussion-the practice of tying a woman upside down by her feet to a fixed frame and bouncing her repeatedly until her prolapse reduced then leaving her bed bound for three days with her legs tied together [ 3].

However, a gradual shift in medical thought began to occur toward the end of the Hippocratic era. Medicine slowly began to free itself from the influence of theurgy. By the first century C.E. Soranus, the most notable gynecologist of antiquity, would rebuke the Hippocratic approaches to treating uterine prolapse. He considered fumigation nonsensical, regarded the use of pomegranates as bruising, and deemed succussion unbearable. Instead, in his monumental treatise, "Gynecology," Soranus prescribed the following: "... bathe the prolapsed part of the uterus with much lukewarm olive oil, and make a woolen tampon corresponding in shape and diameter to the vagina and wrap it in very thin clean linen... one should dip it briefly in vinegar... acacia juice... or wine, and apply it to the uterus and move the whole prolapsed part, forcing it up gently until the uterus has reverted to its proper place and the whole mass of wool is in the vagina" [ 4]. Yet, despite this therapeutic advance, outdated notions about the uterus would persist. As late as the second century C.E., prominent Greek physician Aretaeus the Cappadocian, in his "Causes and Indications of Acute and Chronic Diseases," still described the uterus as, "an animal within an animal" [ 5].

Despite Soranus's vast knowledge of obstetrics and gynecology, female pelvic anatomy remained poorly understood. Physicians of the age commonly referred to the uterus as mater (Latin for mother) or hystera (Greek for womb) in the plural form, believing the uterus consisted of more than one chamber [ 3]. Had it not been for Rome's prohibition on the use of human cadavers, this belief might have been dispelled by the work of Galen, the Rome based physician and anatomist. However, Galen was left to extrapolate his understanding of human anatomy from dissections and vivisections of lower animals in which the finding of uterine horns was commonplace [ 3].

The Mediaeval era brought about a return to theurgy, and medicine, including the management of uterine prolapse, regressed. It was during the Middle Ages that fantastical concepts regarding female pelvic anatomy emerged. The seven cells doctrine was one such concept. It stated that the uterus consisted of seven compartments, three on each side and one in the middle and posited that female fetuses developed on the left, male fetuses on the right, hermaphrodites in the middle [ 6]. Beliefs from the Hippocratic era resurfaced and as late as 1603, a text by Roderigo de Castro advised that the prolapsed uterus, "be attacked with a red-hot iron as if to burn, whereupon fright will force the prolapsed part to recede into the vagina" [ 3]. While the practice of medicine during the Middle Ages left much to be desired, in the middle of the fifteenth century changes in the way people thought about art and philosophy would soon lead to new ways of thinking in medicine.

3. Evolution of the Pessary

By the close of the sixteenth century, the management of uterine prolapse became more firmly rooted in the use of pessaries. Pessaries would evolve from lint balls or halved fruit soaked in vinegar to something closer to their modern form. This shift was largely due to the inventiveness of France's royal surgeon, Ambroise Paré. Paré devised oval shaped pessaries of brass and waxed cork. He attached thread to them to facilitate their removal, while others were to be worn with belts to help them remain in situ [ 8]. In the eighteenth century, Henrick van Deventer, who started his career as a goldsmith, made pessaries of various shapes and sizes out of waxed cork or wood, and metals such as silver and gold [ 9]. By the mid-nineteenth century, pessary use had become quite common. Yet, alternative methods of managing prolapse were still prescribed. These included the use of astringents such as tannin and alum; cold sitz baths, surf bathing, and sea-water douches; postural exercises; Brandt's "uterine gymnastics" which embodied anointing, massage, and manual replacement of the prolapsed parts; leeching; torsion of the uterus; attempts to produce fibrosis of the surrounding tissues by the introduction of gonorrheal exudates into the vagina or the deliberate induction of pelvic peritonitis [ 10].

Hugh Hodge of Philadelphia (who was concerned with ailments he believed to be caused by uterine retroversion) was a major proponent of pessary use. He shared the sentiments of many gynecologists in the United States and abroad when, in 1860, he proclaimed pessary use to be the "sine qua non" for the treatment of uterine displacements [ 11]. He put forth the following as the ideal qualities for a pessary: it should be made of incorruptible material, maintain the normal uterine position, allow for natural movement, be worn without pain, and not excite leucorrhea or menorrhagia [ 12]. The first of these, to be incorruptible, came to pass in 1844 when Charles Goodyear was granted U.S. patent no. 3,633 for the invention of vulcanized rubber [ 13]. Before then, pessaries had consisted of wax, wood, leather, glass, and metal. Now a material could be used that resisted decomposition. This ultimately led to the development of Hodge's eponymous lever pessary and was followed by an explosion in the number and variety of pessaries put to use by gynecologists. It was said in those years that fortunes were made by two groups of gynecologists: those who inserted pessaries and those who removed them (a bit reminiscent of vaginal mesh use today) [ 12].

However, not everyone in the profession was so keen on pessary use. In 1866, during his satirical presidential address to the New Hampshire State Medical Society, W. D. Buck commented, "The Transactions of the National Medical Association for 1864 has figured one hundred and twenty-three different kinds of pessaries, embracing every variety, from a simple plug to a patent threshing machine, which can only be worn with the largest hoops. They look like the drawings of turbine water-wheels, or a leaf from a work on entomology. Pessaries, I suppose, are sometimes useful, but there are more than there is any necessity for. I do think that this filling the vagina with such traps, making a Chinese toy-shop of it, is outrageous" [ 14]. Despite this sentiment, pessaries would remain popular throughout the eighteen hundreds. However, with the discoveries in asepsis by Lister and anesthesia by Morton, paired with advances in suture materials and surgical instruments, surgery would soon replace the pessary as the predominant method of treating uterine prolapse.

4. The Rise of Surgery

The surgical management of uterine prolapse has been recorded as far back as the second century C.E. Soranus advised, "cutting off the black part," when the prolapsed uterus became gangrenous [ 4]. Similarly, Berengario claimed he witnessed his father, a surgeon, remove a prolapsed uterus by scalpel asserting that not only had the patient survived, but also she was able to resume coitus. He later claimed to have achieved the same outcome using strong twine as an ecraseur [ 3]. Later, the prominent seventeenth century Dutch gynecologist Hendrik van Roonhuyse reported a case in which he extirpated a prolapsed uterus after multiple attempts by other caregivers had failed to adequately restore the organ (previously placed pessaries made of cork and wax had led to ulcerations, pain, foul discharge, putrefaction, and fever). The patient was reported to have survived, but van Roonhuyse provided no details of his surgical technique or of an anesthetic used, if any [ 3]. In these early reports it remains unclear whether "hysterectomy" meant removal of the cervix, the cervix and a portion of the uterus, or the uterus in total.

5. Mechanisms of Uterine Support

In 1895, while practicing in Berlin, Alwin Mackenrodt published his comprehensive, and accurate, description of the female pelvic floor connective tissue. In regard to what have become known as the Cardinal or Mackenrodt ligaments he remarked: "This whole ligamentous apparatus appears so excellent and extensive that it is quite surprising that it has not been recognized previously" [ 12]. Shortly thereafter, Fothergill, building upon the work of his senior colleague, the prominent Manchester obstetrician gynecologist Archibald Donald, recognized the importance of the Cardinal ligaments to uterine support and perfected what became known as the Manchester-Fothergill surgery. Fothergill's procedure involved dissecting the bladder off the lower uterine segment followed by plication of the parametrial and paravaginal tissue at the anterior aspect of the cervix, thus effectively shortening the uterine supports. He would combine the aforementioned steps with an anterior and posterior colporrhaphy and perineoplasty to keep recurrence in check [ 12, 18] and later would advocate cervical truncation as part of the surgery [ 19]. Fothergill would become a vociferous proponent of the belief that the parametrial (and paravaginal) fascia was the key structure to maintaining uterine support [ 20]. Referring to Peter Thompson's research on the comparative morphology of the levator ani muscles in tailed apes and man [ 21], he considered the levator ani muscles withered muscle bodies no longer required to carry out their original function (tail movement) and therefore deemed them inadequate supports for the uterine body. He remarked, "Injuries to the perineum and levator ani doubtless straighten and widen the road from the pelvic cavity to the exterior. But if the organs remain firmly attached above, no mere enlargement of the opening below will make them come down." To bolster his thesis, Fothergill was fond of noting, "The true supports of the uterus can be seen at vaginal hysterectomy... Let him incise... round the cervix, and... freely divide the posterior attachments...Next let the operator deliver the fundus... this affords another proof that the broad and round ligaments have no value as suspenders... the uterus still remains fixed by the tissue known as the parametrium, and by this alone. Until this is divided... the organ is... as completely supported as before an incision was made" [ 20].

In 1934, Bonney published, "The Principles that Should Underlie All Operations for Prolapse." Using basic analogies such as an in-turned finger of a rubber glove and the securing of stove piping in a metal box, Bonney was able to convey the manner in which the pelvic viscera are supported [ 22]. These concepts would later be refined by DeLancey and described as levels of fascial supports: level I: proximal suspension; level II: lateral attachments; level III: distal fusion [ 23].

In 1936, Mengert, inspired by 1858 cadaveric data from Legendre and Bastien, published a simple but influential study in which cadaveric uteri were subjected to traction with a 1 kg weight while structures attached to the uterus were severed in various sequences. The uterine descent observed after incising the parametrial tissues reinforced Mackenrodt's anatomic research and Fothergill's clinical observation, suggesting the parametrial and paravaginal tissues (i.e., cardinal and uterosacral ligaments) were the primary support structures for the uterus [ 24].

However, Mackenrodt and Fothergill were not lone voices. In 1907, a gynecologist, Josef Halban, and anatomist, Julius Tandler, professors at the famed Vienna Medical School [ 25], published Anatomie und Atiologie der Genitalprolapse beim Weibe [ 26]. Their thesis on uterine support was quite contradictory to Mackenrodt and Fothergill's. Halban and Tandler maintained that the pelvic fascia was like a spider's web, able to bear the proper weight of the spider, but incapable of supporting a greater, abnormal burden [ 27]. Thus, it was the levator ani muscles that were essential to maintaining uterine support. Like Fothergill, they too turned to the comparative anatomic work of Peter Thompson but drew a different conclusion. Consistent with a prime tenet of the Vienna School, form follows function [ 25], Halban and Tandler viewed the functional adaptation of the levator ani muscles from their tail wagging purpose to that of maintaining pelvic floor support as evidence they were not superfluous muscle bodies (otherwise they would have regressed with the tail), but significant [ 28]. Others who were sympathetic to Halban and Tandler's thesis would point to the observation of large prolapses in patients with mal-developed pelvic floor muscles from spina bifida, to the work of Goff, who asserted that the "fascia" described in vaginal plastic procedures was the "loosely arranged areolar type," as well as the work of Berglas and Rubin, who demonstrated the complete absence of ligamentous material in the endopelvic fascia [ 27, 29, 30]. In time, pelvic floor surgeons would recognize the importance of both structures [ 31] influencing new approaches to repair uterine prolapse.

6. Vaginal Hysterectomy and Vault Prolapse

Vaginal hysterectomy was first performed and developed in attempts to treat cervical and uterine malignancies [ 15]. The first vaginal hysterectomy for uterine prolapse was reported by Choppin, of New Orleans, in 1861. The surgery was conducted under chloroform and the removal of the uterus, after it was dissected away from the bladder and rectum, was excised using "Chassaignac's Ecraseur." A little more than a month after the surgery, Choppin presented the patient to the class of the New Orleans School of Medicine, the patient holding the specimen in hand [ 32]. Choppin's success was a rarity. However, as the new century arrived this fact would change. By 1915, Mayo would publish his technique for vaginal hysterectomy [ 33], as would Bissell, in 1918, coupling his technique of vaginal hysterectomy with an anterior and posterior colporrhaphy [ 34]. The rapid rise of surgery for the correction of uterine prolapse in the early twentieth century left one American gynecologist to write in 1923, "Gynecology has become so predominantly a surgical specialty... the young gynecologist of today frequently has no conception of what the pessary is meant to do and he is apt to be even irritated at the suggestion that such an implement should be accorded at least a modest position in his armamentarium" [ 35]. In the spring of 1937, at the sixty-second Annual Meeting of the American Gynecological Society, Baer and his colleagues reported on the type of operations performed for uterine prolapse in 1928 compared to those performed in 1937. They noted that by the latter date vaginal hysterectomy had become the predominant operation, replacing interposition [ 36]. Modifying the surgical methods established by Mayo, and others, McCall, in 1957, published his technique of obliterating the cul-de-sac of Douglas to cure an enterocele and prevent subsequent vault prolapse [ 37]. By the mid-twentieth century, vaginal vault prolapse had become a recognized sequela of hysterectomy. Thus, in 1965, Symmonds and Sheldon were able to report on the number of posthysterectomy vaginal vault prolapse cases they had observed at the Mayo Clinic [ 38].

Long before the sacral promontory had been considered a fixation point for correcting apical prolapse, Zweifel of Germany, in 1892, commented on his attempts to correct uterovaginal prolapse by using silkworm sutures to unilaterlly affix the upper vagina to the sacrotuberous ligament

Since Randall and Nichols' 1971 publication, the procedure has changed little [ 48, 49]. The most notable modifications have been related to instrumentation: the introduction of the Miya Hook [ 50], the Shutt needle driver [ 51], and the Laurus needle driver, presently known as the Capio (Boston Scientific, Natick, MA) [ 52]. Other reported surgical approaches to correct vault and advanced uterine prolapse include the iliococcygeus fixation (first described by Inmon) [ 53], endopelvic fascia fixation [ 54, 55], coccygeous muscle fixation [ 56], high uterosacral ligament suspension [ 57, 58], and levator myorrhaphy [ 59]. Thus, upon exiting the twentieth century, it had been the effort and ingenuity of a multitude of accomplished surgeons, attempting to prevent and correct vaginal vault prolapse, which led to many of the surgical techniques presently used to correct advanced apical prolapse. Notably, of the surgeries established in the nineteenth century, only the LeFort colpocleisis has endured.

7. Quantifying Prolapse

In October 1995, the International Continence Society formally adopted the document that would introduce the Pelvic Organ Prolapse Quantification (POP-Q) to the larger gynecology community. This document, three years in the making, and validated in six centers in Europe and the United States, would replace Baden-Walker and other descriptive measures as the means to objectively report findings of pelvic organ prolapse [ 60]. Subsequently, the POP-Q has become the standard means by which to report pelvic organ prolapse in the international literature and has been increasingly embraced by physicians in their clinical practices [ 61]. However, the POP-Q is not without its potential confounders [ 62, 63]. Thus, both clinicians and clinical investigators have turned to the various imaging modalities that allow for in situ evaluation of the female pelvic organs and their supporting structures.

Imaging pelvic floor anatomy can be traced back to Berglas and Rubin's method of levator myography in which they injected radio-opaque dye into the levator ani muscles, vagina, and endocervix, revealing by X-ray that the vagina did not rest at a steep incline, but rather lie almost horizontal, parallel to the levator plate [ 64]. Since that time, both magnetic resonance imaging (MRI) and sonography have advanced notably to better visualize the pelvic floor. Hedvig Hricak first described female pelvic anatomy by MRI in 1983 [ 65]; however, he was most concerned with its ability to differentiate benign versus malignant conditions involving the pelvic organs [ 66]. Yang and colleagues, in 1991, would introduce dynamic MRI. This would allow MR images to be taken during valsalva [ 67]. Further, 2D and 3D MRI has been used in research studies to evaluate levator ani status in women with and without pelvic floor disorders [ 68, 69].

The most recent advances in MRI technology, such as HASTE (half-Fourier-acquisition single shot turbo spin echo technology), FISP (fast imaging with steady-state free precession), and TSE (turbo spin-echo), allow for the fast acquisition of images simultaneously in all three compartments (anterior, central, and posterior), making MRI a valuable option to aid in the evaluation of pelvic floor disorders, including prolapse. Already, MRI is replacing fluoroscopy as the means to perform defecography studies in some institutions, and it continues to be evaluated in research protocols investigating its potential role in the clinical evaluation of pelvic organ prolapse [ 70].

8. Apical Prolapse Surgery in the 21st Century

Two major shifts have occurred in the surgical management of apical prolapse in current practice: the introduction of vaginal mesh and that of advanced endoscopic surgery.

Graft use in pelvic reconstructive surgery can be traced back to the early 1900s [ 76]. In 1955, Moore and colleagues reported the use of tantalum mesh in the repair of cystoceles [ 77]. The concept that pelvic organ prolapse is a type of hernia, comparable to other fascial defects, made attractive the idea of replacing weakened fascia of the pelvic floor with a more reliable biologic or synthetic material. Over the intervening years, a number of auto-, allo-, and xenografts have been used with this intent in pelvic floor repairs. However, the success general surgeons achieved using polypropylene mesh in the correction of incisional hernias significantly influenced the use of this mesh by pelvic floor surgeons (type I monofilament, macroporous polypropylene mesh becoming the standard) [ 78]. Additionally, the success of the tension-free transvaginal tape (TVT) mid-urethral sling with its facility of use, clinical effectiveness, and marketability as an all-inclusive "kit" demonstrated the potential for mesh to improve surgical outcomes and opened a market in women's health care medical device manufacturers could exploit. In 2001, Petros introduced the infracoccygeal sacropexy (Intravaginal Slingplasty Tunneler, Tyco, USA) as a novel means to transvaginally correct vault prolapse using polypropylene mesh [ 79]. Petros' mesh was multifilament and complications due to perirectal abscesses and fistula formation led to its removal from the market. However, since that time, a steady stream of mesh "kits" have been engineered by medical device makers and have made their way into the hands of many pelvic floor surgeons for the purpose of correcting apical and other forms of prolapse. Yet controversy has and continues to surround the use of vaginal mesh particularly as its acceptance in clinical use has outpaced the development of well-designed clinical trials [ 80]. In 2006, the French Health Authorities (HAS) reported that mesh for transvaginal repair of pelvic organ prolapse should be limited to clinical research [ 81]. In 2008, the US Food and Drug Administration (FDA) issued a warning regarding the use of mesh for prolapse and incontinence repair [ 82], repeating that warning in 2011, although narrowing it to vaginal mesh used to correct pelvic organ prolapse (not for anti-incontinence procedures or when used abdominally) [ 83]. These warnings stemmed from concerns over mesh erosion through the vagina, pain, infection, bleeding, dyspareunia, organ perforation, and urinary problems. While many of these complications are common to all pelvic floor repairs, mesh erosion and some types of organ perforation are surely unique to mesh and the trocars used for its placement. Presently, with respect to apical prolapse, no published, well-designed, randomized controlled trials have established the superiority of vaginal mesh over native tissue repairs [ 84]. This is beginning to change with respect to the anterior compartment [ 85].

What the future holds for vaginal mesh in pelvic organ prolapse repairs is uncertain. Nevertheless, while biomaterials improve and the subspecialty weighs the appropriate indications for their use, advances in endoscopic repairs for apical prolapse surge forth.

It has been the efforts of many physicians from the global scientific community that have brought forth the modern state of laparoscopy in gynecologic surgery. The pioneering works of Georg Kelling, Hans Christian Jacobaeus, John C. Ruddock, Janos Verees, and Kurt Semm all deserve further mention; however, a discussion of their contributions is beyond the scope of this paper [ 86- 88].

The recent advances in endoscopic technology have been remarkable, and they have allowed urogynecologists to make endoscopic surgery a primary tool in their surgical armamentarium. It has been of great benefit to patients that what many believe to be the most durable apical prolapse repair, abdominal sacrocolpopexy, is achievable via minimally invasive approaches [ 89]. Presently, a debate exists regarding what method of sacrocolpopexy (straight sticks versus robotic assisted) should become the predominant technique taught and performed by urogynecologist in light of differences in cost, patient safety, surgeon training, and surgical outcomes. Well-designed studies have started to shed light on this issue [ 90, 91], but it is a conversation that is only beginning. And yet, in the shadow of that debate gynecologists are already reporting their early experiences with single incision laparoscopic surgery (SILS, or LESS-laparoendoscopic single-site surgery) and natural orifice transluminal endoscopic surgery (NOTES) [ 92, 93]. Whether these new surgical approaches will be amenable to performing safe and timely apical and other prolapse repairs remains to be seen. Nevertheless, a SILS sacrocolpopexy has been reported [ 94].

9. Conclusion

Uterine prolapse is an age-old condition the treatment of which has evolved over thousands of years. It is a condition from which many women have suffered and that many physicians have attempted to treat. The slow historical progress of the field and the challenges that we face today in treating uterine prolapse reflect the very intricacies of this disorder that fascinate and inspire us. Today, not only do urogynecologists reap the benefits gleaned from the developments over the ages, but also from the advances in modern technology. We are now positioned to more effectively evaluate and treat this condition and to enhance our understanding of its causes through the pursuit of novel research.

References

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Uterine Prolapse: From Antiquity to Today

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Uterine prolapse is a condition that has likely affected women for all of time as it is documented in the oldest medical literature. By looking at the watershed moments in its recorded history we are able to appreciate the evolution of urogynecology and ...