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Summary

Recently, Blümel et al. [1] published data of a cross-sectional study performed in seven Latin American countries aiming to compare urogenital symptoms, including sexuality, of women with primary ovarian insufficiency (POI) to those without the condition. For this, 1,190 postmenopausal women (n=401 had POI; and n=789 did not) were surveyed with a general questionnaire, the Menopause Rating Scale (MRS) and the six-item Female Sexual Function Index (FSFI-6). The association of POI with more urogenital symptoms and lower sexual function was evaluated with logistic regression analysis. Authors found that women who had experienced POI currently presented more urogenital symptoms (MRS urogenital score: 3.54 ± 3.16 vs. 3.15 ± 2.89, p < 0.05) and had lower sexual function (total FSFI-6 score: 13.71 ± 7.55 vs. 14.77 ± 7.57 p < 0.05) than women who experienced menopause at a normal age range. There were no significant differences in symptoms when comparing women based on the type of POI (idiopathic or surgical). After adjusting for covariates, the logistic regression model determined that POI was associated with more urogenital symptoms and lower sexual function. Researchers conclude that POI, whether idiopathic or secondary to bilateral oophorectomy, is associated with symptoms that affect vaginal and sexual health.

Commentary

Premature menopause refers to the permanent cessation of menstruation before the age of 40 [2]. Despite this, some women who experience prolonged periods of amenorrhea before that age can start menstruating again and even become pregnant. So, for this reason, when a clinician encounters a young woman with amenorrhea lasting more than a year, it is preferred to use the term POI. This is because we cannot determine whether she will eventually menstruate again. The prevalence of POI has varied over the years, with a trend towards an increase, also with variations related to the studied region (geography/economic status).

There are limited studies on urogenital symptoms in women who have experienced menopause before the age of 40 (idiopathic or surgical due to bilateral oophorectomy), which makes this study very interesting. The study basically shows that women who had POI (idiopathic and surgical) at present have more urogenital complaints and lower sexual function than women who presented menopause at a later age, with no differences observed when type of POI was compared.

Women who have had surgical menopause display lower estradiol levels when compared to women who present natural menopause and at a normal range of age [3]; in some sense, this suggests that women with idiopathic POI have hypoestrogenism similar to that of women with surgical POI and lower than non-POI women. Although women at the moment of the survey, POI or not, had similar mean age, those who had experienced POI have spent more time with lower estradiol levels, and hence the impact on sexuality and the urogenital system is worse, hence, quality of life is more severely impaired. This highlights the importance of estradiol on the normal functioning of organs and systems, in this case the sexual and urogenital sphere.

Authors acknowledge very clearly the limitations of the study, such as the cross-sectional design, that does not allow determining causality and the mixture of women attending public and private healthcare, which imposes selection bias. Another important limitation was not being able to compare POI women in their first few years of postmenopause with women of the same age who are still menstruating. Such a comparison would have been more appropriate since the symptomatic differences would have been more noticeable when compared to young women. In any case, the study has its strengths, such as the representation of common characteristics of Latin American women, including ethnicities, cultural and socioeconomic factors, and social female roles. Furthermore, authors included a multinational sample of women living in Latin America, and validated tools were used specifically for that population.

In conclusion, POI, regardless of whether it is idiopathic or secondary to bilateral oophorectomy, is associated with symptoms that impair vaginal health and sexuality. For this reason, doctors must be aware of this condition to perform a prompt diagnosis and ensure appropriate therapeutic measures that will prevent the impairment of female quality of life.

Danny Salazar-Pousada, MD
Universidad Católica de Santiago de Guayaquil, Guayaquil Ecuador

References

      1. Blümel JE, Chedraui P, Vallejo MS, Dextre M, Elizalde A, Escalante C, Monterrosa-Castro A, Ñañez M, Ojeda E, Rey C, Rodríguez D, Rodrigues MA, Salinas C, Tserotas K. Genitourinary symptoms and sexual function in women with primary ovarian insufficiency. Climacteric. 2024 Feb 3:1-6. doi: 10.1080/13697137.2024.2306278.
        https://pubmed.ncbi.nlm.nih.gov/38308574/
      2. “The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
        https://pubmed.ncbi.nlm.nih.gov/35797481/
      3. Korse CM, Bonfrer JM, van Beurden M, et al.  Estradiol and testosterone levels are lower after oophorectomy than after natural menopause. Tumour Biol. 2009;30(1):37–42.
        https://pubmed.ncbi.nlm.nih.gov/19194113/

If you would like to add a comment or contribute to a discussion based on this issue, please contact Menopause Live Editor, Peter Chedraui, at  peter.chedraui@cu.ucsg.edu.ec.

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