Healthcare Research: Worksheet 18 Synthesis of Findings Assignment

This assignment synthesizes research findings on the alleviation of discomfort in postmenopausal women with vaginal atrophy, comparing vaginal estrogen to vaginal moisturizer. It analyzes a randomized clinical trial (RCT), a clinical practice guideline (CPG), and a qualitative study, identifying strengths and weaknesses based on JBI and AGREE appraisals. Strengths include the determination of hormonal therapies' effectiveness, the assessment of lubricants and moisturizers, and the exploration of women's perceptions of vaginal atrophy. Weaknesses include a relatively homogenous population, the lack of direct comparison between active interventions, and a small sample size. The main conclusion highlights the effectiveness of both hormonal and nonhormonal therapies, the importance of considering women's perceptions, and the clinical applicability of the findings in guiding patient care by recommending estradiol tablets and/or moisturizers. The PICO question is answered through the RCT and CPG, but not by the qualitative study. The synthesis emphasizes the need for healthcare professionals to consider both the physical and emotional aspects of the condition and to incorporate patient preferences in treatment decisions.

Running head: WORKSHEET
Synthesis of Research Findings
Name:
Faculty:
Date:

1WORKSHEET
Synthesizing Questions: Identify and succinctly state the following related to the sum of the
evidence in your identified articles. Use APA format for citations as appropriate when referring
to specific articles.
**Key Question**
RCT Article (citation) CPG (citation) Qualitative (citation)
In healthy
postmenopausal women
with symptoms of
vaginal atrophy, how
does vaginal estrogen
compared to vaginal
moisturizer alleviate
discomfort?
Mitchell, C. M., Reed,
S. D., Diem, S., Larson,
J. C., Newton, K. M.,
Ensrud, K. E., ... &
Guthrie, K. A. (2018).
Efficacy of vaginal
estradiol or vaginal
moisturizer vs placebo
for treating
postmenopausal
vulvovaginal
symptoms: a
randomized clinical
trial. JAMA internal
medicine, 178(5), 681-
690.
Stuenkel, C. A., Davis,
S. R., Gompel, A.,
Lumsden, M. A.,
Murad, M. H.,
Pinkerton, J. V., &
Santen, R. J. (2015).
Treatment of symptoms
of the menopause: an
endocrine society
clinical practice
guideline. The Journal
of Clinical
Endocrinology &
Metabolism, 100(11),
3975-4011.
Utian, W. H., &
Maamari, R. (2014).
Attitudes and
approaches to vaginal
atrophy in
postmenopausal
women: a focus group
qualitative
study. Climacteric, 17(1
), 29-36.

2WORKSHEET
NOTE: *The answer to this question will impact the “weight” you put into the findings of this
article for synthesis and dissemination. If you determine it is NOT a strong article
methodologically, do not use its findings as recommendations for patient care.*

3WORKSHEET
Strengths: What are 3 strengths related to this collection of evidence? Think about your critical
appraisals, including the methodology, and presentation of results. Findings of an article are
NOT a strength. At least 2 articles need to share each strength. Give a rationale for why this is a
strength, acknowledging the JBI or AGREE appraisal.
Strength APA
Citations
of Articles
that share
this
strength
(at least 2
for each
strength)
JBI or
AGREE
tool item
or
concept
from
appraisal
Rationale for why
this is a strength-
why this item is
important.
Tie Strength into
article specifics.
(cite from the
article here)
Exampl
e
The samples
were well
described at
baseline and
findings are
generalizable
to the general
population
RCT
citation
Qual
citation
JBI RCT:
Were
treatment
groups
similar at
baseline?
JBI Qual:
Are the
participan
It is important if
these findings are
to be applicable to
the current PICO
question that the
sample is well
described and
generalizable.
This increases the
The RCT article
described the two
groups well at
baseline and noted
differences in
educational level
only.
The Qual article
ensured that the

4WORKSHEET
ts and
their
voices
adequatel
y
represente
d?
validity of the
work.
voices of all
participants were
heard by utilizing
numerous
researchers to
analyze the
transcripts.
1. Determined
the short term
effectiveness
of
recommended
hormonal
vaginal
therapies for
management
of
postmenopausa
l vulvovaginal
symptoms.
Mitchell et
al. (2018)
Stuenkel
et al.
(2015)
AGREE
domain 1:
scope and
purpose-
The
health
question(s
) covered
by the
guideline
is (are)
specificall
y
described
?
Determining the
impact of
hormonal vaginal
therapies is
significant owing
to the fact that
after the onset of
menopause, the
level of the
estrogen hormone
becomes
considerably low,
in addition to
thinning of the
vaginal lining,
which
The RCT measured
vaginal mucosal
cell maturation
owing to effects of
estrogen. In
addition the RCT
stated that
hormonal therapy
helped in
increasing the pH
of the vaginal cells
and also increased
VMI superficial
cells.
The guideline
suggested that

5WORKSHEET
demonstrates a
reduced number of
folds. Therefore,
the flexibility of
the vaginal lining
decreases and
vaginal secretions
get reduced. This
eventually leads to
a decrease in
lubrication. Hence,
investigating the
impacts of both the
types of therapy
was helpful since
the vaginal region
requires sufficient
amount of estrogen
hormone for
maintaining
integrity of the
tissues (Tiidus,
2017). In addition,
vaginal estrogens
when applied in
low dosage were
able to effectively
alleviate the
symptoms rapidly
such as, vaginal
dryness,
dyspareunia,
dysuria and urge
incontinence.

6WORKSHEET
estrogen receptors
are located in the
vaginal epithelium,
which when
triggered by the
hormone, plays an
important role in
keeping the walls
elastic and thick.
In addition,
considering
hormonal therapy
can be considered
a strength since
decreased estrogen
also predisposes
the exposed and
sensitive tissues to
chafing.
2. Determined
the
effectiveness
of vaginal
Mitchell et
al. (2018),
Stuenkel
et al.
JBI- Were
treatment
groups
treated
Determining the
effectiveness of
vaginal moisturizer
was relevant to the
The RCT
elaborated on the
fact that application
of vaginal

7WORKSHEET
lubricants and
moisturizer in
reducing
postmenopausa
l vulvovaginal
symptoms.
(2015) identicall
y other
than the
interventi
on of
interest?
Was the
search
strategy
appropriat
e?
research since
under normal
circumstances, the
walls of
the vagina generall
y remain lubricated
due to the presence
of a thin layer
composed of clear
fluid. Owing to the
fact that normally
the fluid keeps the
vaginal lining
thick, healthy, and
elastic, reduction
in the amount of
available moisture
is a significant
symptom
manifested during
menopause
(Gibson et al.,
2019).
moisturizers such
as, replen that
comprise
of polycarbophil lik
e mucoadhesives
are able to reduce
severity of the
symptoms to a
certain extent.
The guideline
highlighted that
vaginal
moisturizers must
be administered at
least twice, each
week among
postmenopausal
females who report
signs and
symptoms of VVA.

8WORKSHEET
Therefore, vaginal
moisturizers must
be applied for
restoring the
moisture in the
vaginal lining,
which in turn will
prevent the onset
and profession of
vaginal dryness.
3. Tried to assess
the perception
of women
about VA in a
manner that
facilitated
exchange of
ideas
Utian and
Maamari
(2014)
JBI- Are
participan
ts, and
their
voices,
adequatel
y
represente
d?
This attribute can
be considered as a
strength of the
article owing to the
fact that any kind
of fluctuations in
estrogen level
interact with the
major chemicals
released from the
brain, thus creating
an impact on the
mood.
The qualitative
study suggested
that although some
females reported
that they could
perceive strength
and pride in their
accomplishments,
they also felt
androgynous,
faded, and
unimportant or
unobserved in this

9WORKSHEET
Furthermore, the
symptoms that are
commonly
experienced in VA
result in emotional
distress among the
females (Ussher,
Hawkey & Perz,
2019). This
strength can also
be related to the
fact that several
women who reach
menopause report
signs of
depression, sleep
problems, panic
disorder, and
schizophrenia.
Therefore,
conducting a
qualitative study
for exploring the
stage of life. The
article also reported
on a theme that was
based on the
disengagement
between a female's
mental perception
wellbeing and self,
which did not alter
with age, with her
physical self tjat
was often perceived
as being in
deterioration.

10WORKSHEET
perceptions and
thoughts that the
women had about
their mental illness
was a notable
aspect.

11WORKSHEET
Weaknesses/ Limitations: What are 3 weaknesses related to this collection of evidence? Think
about your critical appraisals, methodology, and presentation of results. At least 2 articles need
to share each weakness. Give a rationale for why this is a weakness or limitation,
acknowledging the JBI or AGREE appraisal.
Weakness/
Limitation
APA
Citations
of
Articles
that
share
this
limitatio
n (at
least 2
for each
limitatio
n)
JBI or
AGREE tool
item or
concept from
appraisal
Rationale for
why this is a
limitation;
why this item
is important
Tie weakness
into the article
specifics (cite
from the
article here)
Exampl
e
Treatment groups
were not treated the
same way and the
interventions
RCT
citation
CPG
citation
JBI RCT:
Were treatment
groups treated
identically
It is essential
for the rigor of
the research
and the rigor of
The
participants in
the treatment
leg of the RCT

12WORKSHEET
weren’t the same
between articles.
other than the
intervention of
interest?
AGREE tool:
There is an
explicit link
between the
recommendatio
ns and the
supporting
evidence
the clinical
practice
guideline to
point to similar
treatment of
groups, and
clear links
between
recommendatio
ns and quality
of evidence.
received more
attention from
the nurses than
those in the
comparison
leg.
The clinical
practice
guideline does
not clearly
explicate the
link between
the
recommendatio
ns and
supporting
evidence.
1. The population was
relatively
homogenous
Mitchell
et al.
(2018),
Utian and
Maamari
(2014)
AGREE:
domain 1
scope and
purpose- The
population
(patients,
Heterogenous
population is
important since
all members of
the sample
have a different
The
participants in
RCT were
women, aged
between 45-70
years who

13WORKSHEET
public, etc.) to
whom the
guideline is
meant to apply
is specifically
described.
value for the
aspect or
feature that is
being measured
(Kohler,
Kreuter &
Stuart, 2019).
resided within
20 miles from
the site of the
clinics and
reported
occurrence of
menopause at
least two years
earlier. Their
symptoms
were also
similar like
dryness,
irritation, pain
and itching.
The qualitative
study also
recruited
participants
who were
postmenopausa
l, aged
between 40-75

14WORKSHEET
years, and
reported signs
and symptoms
of VA.
2. No direct
comparison
between active
interventions
Mitchell
et al.
(2018),
Stuenkel
et al.
(2015)
AGREE:
domain 1
scope and
purpose- The
population
(patients,
public, etc.) to
whom the
guideline is
meant to apply
is specifically
described.
Head to head
assessment to
different
interventions
help in
comparing the
potential
efficacy and
drawbacks of
each type of
intervention,
thus providing
a statement
about the
intervention
that is most
operative.
The RCT
compared
vaginal
estradiol tablet
against placebo
and vaginal
moisturizer
against
placebo, and
not with each
other.
The clinical
guideline did
not compare
between the
different
interventions,
however,
provided

15WORKSHEET
adequate
information on
the
effectiveness
of menopausal
hormone
therapy
(MHT),
ospemifene,
and low-dose
vaginal
estrogen
3. Small sample size Mitchell
et al.
(2018),
Stuenkel
et al.
(2015)
JBI- Was true
randomization
used for
assignment of
participants to
treatment
groups?
JBI- Were the
sources and
resources used
to search for
Small sample
size reduces
representativen
ess of the
complete
population. It
also creates an
impact on
reliability of
the results
(Malterud,
The RCT
recruited 302
women.
The clinical
guideline was
based on three
systematic
reviews

16WORKSHEET
studies
adequate?
Siersma, &
Guassora,
2016).

17WORKSHEET
Main Conclusion:
The RCT was the first study that determined the short-term (12 weeks) effectiveness of
suggested hormonal and nonhormonal vaginal therapies for management of postmenopausal
vulvovaginal symptoms, and contained a dual placebo arm. Reduction in levels of estrogen bring
about a sudden increase in pH of the vagina, itching, dryness, and pain thus adding to the
suffering of the affected women. The clinical guideline provided a comprehensive overview of
different interventions that can be implemented upon postmenopausal women with the aim of
striking a balance between relief from menopausal symptoms. The qualitative study tried to
ascertain the feelings and perception of the target population about postmenopausal symptoms.
This was important since most patients considered VA as frightening, thus identifying the need
of changing their views and perceptions, to improve health and wellbeing.
PICO Question:
The PICO question was the following:
In healthy postmenopausal women with symptoms of vaginal atrophy, how does vaginal
estrogen compared to vaginal moisturizer alleviate discomfort?
The RCT and clinical guideline provided adequate evidence and facts that helped in
determining the role of the aforementioned interventions in alleviating the discomfort that is
generally experienced by postmenopausal women. However, this PICO question was not
answered by the qualitative study since it did not compare the two types of intervention, and only
provided an overview of the perceptions that women had about the health condition.
Clinical Applicability and Shared Decision Making:

18WORKSHEET
Synthesis of this evidence will help patient care by encouraging healthcare professionals
to recommend the application of estradiol tablet and/or moisturizer for the effective management
of postmenopausal symptoms. Owing to the fact that these symptoms comprise of itching,
burning sensation, dryness, and UTI, the findings will pave the way for high quality patient care
that will not only address the signs, but will also take into consideration the preferences and
perceptions of the women.

19WORKSHEET
References
Gibson, C. J., Li, Y., Bertenthal, D., Huang, A. J., & Seal, K. H. (2019). Menopause symptoms
and chronic pain in a national sample of midlife women veterans. Menopause, 26(7),
708-713.
Kohler, U., Kreuter, F., & Stuart, E. A. (2019). Nonprobability sampling and causal
analysis. Annual review of statistics and its application, 6, 149-172.
Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample size in qualitative interview
studies: guided by information power. Qualitative health research, 26(13), 1753-1760.
Mitchell, C. M., Reed, S. D., Diem, S., Larson, J. C., Newton, K. M., Ensrud, K. E., ... &
Guthrie, K. A. (2018). Efficacy of vaginal estradiol or vaginal moisturizer vs placebo for
treating postmenopausal vulvovaginal symptoms: a randomized clinical trial. JAMA
Internal medicine, 178(5), 681-690.
Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V., &
Santen, R. J. (2015). Treatment of symptoms of the menopause: an endocrine society
clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism,
100(11), 3975-4011.
Tiidus, P. M. (2017). Estrogen and menopause: Muscle damage, repair and function in females.
In Sex Hormones, Exercise and Women (pp. 71-85). Springer, Cham.
Ussher, J. M., Hawkey, A. J., & Perz, J. (2019). ‘Age of despair’, or ‘when life starts’: migrant
and refugee women negotiate constructions of menopause. Culture, health &
sexuality, 21(7), 741-756.

20WORKSHEET
Utian, W. H., & Maamari, R. (2014). Attitudes and approaches to vaginal atrophy in
postmenopausal women: a focus group qualitative study. Climacteric, 17(1), 29-36.