Knowledge, Confidence Barriers Hinder Effective Management of Vulvovaginal Atrophy

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Barriers to effective treatment of vulvovaginal atrophy were identified, including lack of time and availability of educational materials for patients.
Barriers to effective treatment of vulvovaginal atrophy were identified, including lack of time and availability of educational materials for patients.

Primary care providers (PCPs) and gynecologists differ in their confidence and knowledge regarding the management of patients presenting with vulvovaginal atrophy (VVA); however, both report similar barriers to effective care, according to a study published in Menopause.

Researchers developed a survey that assessed clinician knowledge; practice behavior and confidence; and perceived barriers to the management of VVA. A total of 360 participants were provided with multiple-choice and Likert-scale questions that assessed knowledge and confidence, as well as a 12-item list that identified potential barriers to VVA care (eg, lack of time, complicated discussions regarding treatment options, lack of available information about treatment options, and patient embarrassment when asking questions). Within a 4-week timeframe, 119 (33%) respondents completed the survey. 

Respondents answered 66% of the knowledge-based multiple-choice questions correctly, with more gynecologists than PCPs identifying the correct answer (77% [range, 50%-100%] vs 63% [range, 25%-88%). Compared with PCPs, gynecologists demonstrated greater knowledge about VVA and estrogen therapy, as well as vaginal estrogen therapy for urinary symptoms.

In total, 39% of clinicians were highly likely or likely to assess for VVA during a well visit, 43% had high or very high confidence in advising patients about VVA symptoms, and 42% had high or very high confidence in their ability to advise patients about vaginal estrogen treatment. Compared with PCPs, more gynecologists indicated being highly likely or likely to assess for VVA symptoms during a routine visit (72% vs 28%), and highly or very highly confident in their ability to counsel on VVA symptoms (72% vs 33%) and to advise on the risks/benefits of vaginal estrogen treatment (76% vs 30%).

Lack of time (71%) was the most commonly identified barrier to VVA diagnosis and treatment, followed by lack of availability of educational materials for patients (44%); difficulty discussing sexual or urinary symptoms with patients was the least common barrier (2%). Gynecologists identified 4 barriers more frequently than PCPs: estrogen as a high-risk medication among older women (adjusted OR = 1.09), the US Food and Drug Administration black box warning for vaginal estrogen prescriptions (OR = 1.36), patient dissatisfaction with options for vaginal estrogen treatment (OR = 2.29), and lack of availability of educational materials for patients (OR = 2.24). The only difference between PCP and gynecologist barriers that was significant involved the cost of vaginal estrogen therapy (GYN 48% vs PC 18%; OR=4.77).

Although gynecologists were found to have greater knowledge about VVA, PCPs frequently manage the gynecologic care of their postmenopausal patients as they age. In addition, “[n]ational surveys of symptomatic postmenopausal women suggest that at least one-third of women do not seek or delay seeking care for their symptoms, and many expect their HCP to raise the issues of vulvovaginal and sexual health with them.” Therefore, “[a]ddressing identified knowledge deficits and practice barriers may lead to improved management of vulvovaginal atrophy,” the researchers concluded.

Reference

Vesco KK, Beadle K, Stoneburner A, Bulkley J, Leo MC, Clark AL. Clinician knowledge, attitudes, and barriers to management of vulvovaginal atrophy: variations in primary care and gynecology [published online August 27, 2018]. doi: 10.1097/GME.0000000000001198

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