LAUSR

REFERENCES We have read with great interest the article ‘‘Clinician knowledge, attitudes, and barriers to management of vulvovaginal atrophy: variations in primary care and gynecology ’’ by Vesco et al. We believe that this study addresses an important subject. There are, however, some methodological concerns that we hope the authors would be willing to address. Vesco et al emphasized in their discussion and conclusions that primary care physicians (PCPs) have less knowledge regarding vulvovaginal atrophy (VVA) than obstetrician/ gynecologist (OB/GYN). This claim is not supported by a recent survey published in Menopause (the WISDOM survey) in which both types of physicians showed similar attitudes and behaviors regarding VVA. Moreover, Vesco et al’s survey had been based on a rather small sample of gynecologists (n1⁄4 29), 86% of whom were women (only four were men), whereas in the PCP group 64% were women (P1⁄4 0.04). Thus, it does not represent the female-to-male ratio of gynecologists in the United States (in 2017, half of the OB\GYN physicians were male). Owing to the small and nonrepresentative sample size, the majority of the ‘‘knowledge-assessment-questions’’ and all the ‘‘practice-behavior-assessment’’ questions have failed to provide a conclusive confidence interval (CI). Indeed, the WISDOM survey is more representative of US physicians than Vesco et al’s. Its results suggest that, in general, a similar treatment for VVA may be given in both PC and OB/GYN settings. Furthermore, as the only two questions in Vesco et al’s survey that achieved statistical significance (had a CI higher than 1) were related to treatment, the conclusion of their findings is hardly persuasive. For example, it could very well be that women clinicians tend to treat VVA more often than male clinicians, as 25 out of the 29 gynecology clinicians in their sample were women. Another possible explanation for the authors’ findings is that advanced practitioners are more likely to treat VVA than physicians, as the proportion of advanced practitioners among the gynecology clinicians was more than twice the proportion of advanced practitioners in the PCP sample (38% vs 17%, P1⁄4 0.02). We hope the authors would be able to furnish better evidence to support their belief that it is the specialty and not the sex or the clinician type that had influenced the study’s results and hence its conclusion.