INTRODUCTION: Decline in circulating estrogen levels after menopause leads to vulvovaginal atrophy (VVA) which can result in symptoms like vaginal dryness, irritation, burning, and dyspareunia. Women seek treatment relatively late, when symptoms are severe, due to embarrassment and/or the mistaken belief that VVA symptoms an inevitable consequence of aging. The European Vulvovaginal Epidemiology Survey (EVES) was a study among postmenopausal women attending menopause centres in Spain or Italy. AIM: The aim of the present analysis was to explore an association between symptom severity, Quality of Life (QoL), sexual function and treatment seeking behaviour. METHODS: Only women who reported at least 1 VVA symptom were included for evaluation. Symptom severity was assessed on a 4-point severity scale, VVA specific QoL assessment was done with the Day-to-Day Impact of Vaginal Aging (DIVA) questionnaire. Sexual functioning was assessed by the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-revised 2005 (FSDS-R). Gynecological included Vaginal Health Index (VHI) and Vulvar Health Index (VulHI). The population was divided into those on treatment (non-hormonal, local vaginal or systemic) vs no treatment. Further analysis was done by treatment type. RESULTS: The presence of VVA on gynaecological exam was confirmed in 91.7% of women on treatment vs. 89.4% not on treatment (p=0.091). Treated women had a statistically significantly worse VVA symptom score (p < 0.0001), a worse VHI (p=0.0060) and VulHI (p < 0.0001) score and a worse DIVA score (p < 0.0001) than those not on treatment. The FSFI score for those treated was better than for those untreated (p=0.015), but the FSD-R score was worse for the former (p < 0.0001). Women on local hormone treatment scored worse in all VVA-related assessments than women on non-hormonal treatment. DISCUSSION: Local vaginal hormonal treatment is effective in treating VVA symptoms. Thus our finding that the symptoms and signs of VVA and the QoL and sexual function in women not treated for VVA is better than in those on treatment suggests that women tend to seek treatment late, when symptoms are more severe, rather than failure of treatment. The study also confirms that most women will start with non-hormonal treatment and will only change to local hormonal treatment if symptoms are getting worse. Early treatment of VVA may prevent further deterioration of symptoms.