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This chapter addresses the following Geriatric Curriculum Fellowship Milestone: #70

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LEARNING OBJECTIVES

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Learning Objectives

  • Establish personal and familial risk factors for gynecologic cancer in each female patient.

  • Discontinue screening for cervical cancer only after adequate screening criteria have been met.

  • Describe the approach to the initial evaluation of vulvovaginal complaints.

  • List multiple options to treat atrophic vaginitis.

  • Understand the indications for specialty referral in a woman with pelvic organ prolapse (POP).

  • Provide reassurance to women who have POP but no medical indication for specialist referral.

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Key Clinical Points

  1. Primary care providers will become increasingly responsible for routine gynecologic care.

  2. Cervical cancer has a higher case-fatality rate in older women, and if a cervix is in situ, screening should be discontinued only in low-risk women age 65+ after three negative cytologies or two negative cotests in the previous decade.

  3. Endometrial cancer associated with a false-negative screening ultrasound is frequently of the more aggressive type.

  4. Although ultrasound and serum (CA-125) screening for ovarian cancer is ineffective in a low-risk population, imaging should be considered in women with suspicious symptoms involving abdominal and pelvic pain/discomfort, bloating, gastrointestinal disturbances, and urinary complaints.

  5. Pelvic pain is not commonly due to pathology of reproductive organs; the urinary tract, gastrointestinal (GI) tract, and musculoskeletal systems should be thoroughly investigated with history and physical examination.

  6. Pessaries can successfully relieve symptoms for many types of POP and stress urinary incontinence, and should be encouraged.

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INTRODUCTION

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The preponderance of women (> 60%) compared to men (< 40%) in a geriatrics practice is not news, but their gynecologic care is changing. With recommendations against routine Pap smears and pelvic examinations over age 65, fewer women will have occasion to see a gynecologist. Gynecologic care will be provided mostly by primary care practitioners, who must be more mindful than ever about risks, symptoms, and unspoken issues. Lifetime risk of a gynecologic cancer (excluding breast cancer) is over 5%, greater than a woman’s lifetime colorectal cancer risk. Pelvic floor symptoms bother 40% of women age 70 to 79 and more than 50% of women greater than or equal to 80 years. Sexual problems are prevalent in half of older women who are still sexually active. Fortunately, compared to reproductive years, gynecologic care for older women is relatively straightforward and well within the scope of primary care management or triage. Urinary and pelvic floor issues are the exception; they increase in complexity with age, but are not foreign to geriatrics practitioners. This chapter seeks to address the most common or important gynecologic and urogynecologic issues encountered in a geriatrics practice, with practical tips and suggestions. Use of the term gynecologic in this chapter usually includes urogynecologic issues as well, except when the topic is cancer. Urinary incontinence is not included in this chapter, but is covered in detail in Chapter 53. Topics are presented anatomically, in approximately the same order as a physical examination is approached, along with the major corresponding clinical issues.

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GYNECOLOGIC WELL-WOMAN VISIT

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In a geriatrics practice it could be argued that the only important gynecologic history is a gynecologic review of systems and a medication list. However, to assess cancer and infectious disease risks, to anticipate and interpret problems, and to promote function and quality of life, more detail is required. If a new patient visit is consumed with other concerns, vaginal bleeding and pelvic or vulvovaginal pain should be queried, since these are most indicative of urgent issues. A more complete gynecologic history and examination could be rescheduled.

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Key points in the gynecologic history and physical are listed in Table 42-1. If gynecologic surgery was performed, note the indication. For pain, prolapse, and incontinence surgeries, determine whether symptoms resolved. Lifetime hormonal status and exposure, family cancer history, and cancer screening since age 55 are important in assessing current cancer risks. Additional useful history includes parity (term/preterm deliveries especially), age at first delivery, delivery route (vaginal or cesarean), major obstetrical complications, and lactation. Since pelvic floor issues may develop regardless of parity, the older the patient, the less relevant the obstetrical history, but it does inform cancer risk.

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Table Graphic Jump Location
TABLE 42-1GYNECOLOGIC HISTORY ...

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