This chapter addresses the following Geriatric Curriculum Fellowship Milestone: #70
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.
Key Clinical Points
Primary care providers will become increasingly responsible for routine gynecologic care.
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.
Endometrial cancer associated with a false-negative screening ultrasound is frequently of the more aggressive type.
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.
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.
Pessaries can successfully relieve symptoms for many types of POP and stress urinary incontinence, and should be encouraged.
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.
GYNECOLOGIC WELL-WOMAN VISIT
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.
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.
TABLE 42-1GYNECOLOGIC HISTORY AND EXAMINATION ||Download (.pdf) TABLE 42-1 GYNECOLOGIC HISTORY AND EXAMINATION
| ||COGNITIVELY INTACT ||COGNITIVELY IMPAIREDa |
|History ||Hormones: menarche, menopause, past and current hormone use. ||Current hormone use. |
| ||Breast complaints: pain, lump, nipple discharge. ||Staining of brassiere or clothing, pain. |
| ||Vulvovaginal issues: bulge, bleeding, discharge, pain. ||Apparent discomfort in perineal area. |
| ||Urinary issues: incontinence, urinary frequency, urinary urgency, hesitancy, nocturia, dysuria, hematuria, infections. ||Toileting practices, pad use. |
| ||Defecation issues: constipation, fecal incontinence (gas, liquid, solid stool). ||Defecation frequency, stool consistency. |
| ||Sexual health issues: sexual activity, contacts, satisfaction, potential sexual abuse. ||Sexual behaviors. |
| ||Family history of gynecologic, breast, intestinal, endocrine malignancies. || |
|Physical examination ||Breast examination (annually) ||Breast examination if tolerated. |
| || |
Routine examinations controversial, low yield
|Annual inspection of the external genitalia is probably useful. Initial internal examination may also be worthwhile. Subsequent internal examinations are indicated for symptoms or to rule out fecal impaction. |
| ||External genitalia and perineum: architecture and integument || |
| ||Urethra: meatus, caruncle || |
| ||Bladder: tenderness, fullness || |
| ||Vagina: mucosal tissue quality, discharge, mass, prolapse || |
| ||Cervix: lesions, mobility || |
| ||Uterus: size and mobility || |
| ||Adnexa: palpability or mass || |
| ||Rectum: anal sphincter tone, mass, stool for occult blood || |
Diethylstilbestrol (DES) is an often-forgotten cancer risk factor. It was synthesized in 1938 and prescribed to pregnant women until the early 1980s in some European countries, although not after 1971 in the United States. An estimated 5 to 10 million women worldwide took DES during pregnancy. An increased breast cancer risk has been seen in both women who received DES and their female fetuses exposed in utero (DES daughters). The increased risk of vaginal clear cell adenocarcinoma and cervical neoplasia in DES daughters continues into the fifth decade, but little is known about epidemiology of these conditions in advanced age.
The physical examination serves four main purposes: (1) to understand the patient’s anatomic status, (2) to detect unrecognized problems at an early stage, (3) to detect significant current problems in the cognitively or neurologically impaired, and (4) to provide the patient an opportunity to discuss embarrassing and private issues. A surprising number of gynecologic and urologic symptoms are only voiced or discovered during the pelvic examination, despite a thorough history and denial of problems. While the utility of an annual pelvic examination is low, a strong argument can be made for examination of a new patient or by a new practitioner assuming care. For example, a forgotten vaginal surgery such as colpocleisis may be discovered. Periodic examination of “asymptomatic” but concerned women is wise. A patient may not be able to articulate the concerns she has. A variety of speculum sizes is essential for a painless examination, including regular, long and narrow, small, and large. Topical lidocaine at the posterior introitus as needed limits discomfort. Local anesthetic can also be applied liberally to the vulva and vagina to facilitate examination in cognitively impaired women. Fecal impaction should be ruled out in older women as a cause of a difficult vaginal examination. Fecal impaction can compress the urethra and bladder (Figure 42-1), can cause urinary symptoms in addition to abdominal discomfort, and requires evaluation of underlying causes (especially poor fluid intake) as well as treatment (see Chapter 95).
Sagittal view of normal pelvic anatomy (left) and fecal impaction (right). Note how a large impaction can compress the bladder, urethra, and surrounding innervation and other tissues.
The American College of Obstetricians and Gynecologists (ACOG) is unique in clearly recommending that “annual examination of the external genitalia should continue” beyond age 65. This is prudent but may not be cost-effective, especially in cognitively intact women who would usually report symptoms. The utility of annual external genitalia examination could be more important in women who are cognitively impaired. Given the possible association with vaginal cancer, ACOG also recommends continuing annual internal pelvic examinations indefinitely in DES daughters, even those who have had a hysterectomy. The benefit of this is unknown.
Screening for breast cancer is addressed in Chapter 97. While numerous studies address cancer, little is known about the epidemiology of benign breast disease in older women. The breast is a complex structure subject to many pathologic conditions, both intrinsic and extrinsic. These may involve skin, connective tissue, ligaments, nerves, vasculature, lymphatics, and muscles in addition to mammary ducts and alveoli.
A clinical breast examination includes axillary, supraclavicular, and infraclavicular lymph nodes. Pertinent negative findings should be documented, ideally in all patients, but especially if there is any breast complaint. These may include “No skin changes, nipple discharge, dominant masses, tenderness, or adenopathy.” Fibrocystic changes in breast tissue are present asymptomatically in the majority of women. Symptomatic problems can be categorized as a lump, pain, nipple discharge, or inflammation.
Evaluation of a lump includes noting the size, position, consistency, and character. Location can be described referencing the areola as a clock face and measuring distance from the areolar border. While a myriad of pathologic entities could result in a breast lump, such as tuberculosis, age is a consistent risk factor for malignancy. A large mammography database study found “lump” to be the only breast symptom significantly associated with cancer, in up to 8% of cases. All discrete lumps should be evaluated by a breast specialist. The diagnostic mammogram and ultrasound may be performed before or after consultation, per consultant preference. If a lump found by the patient is not palpated by the physician, additional consultation is in order. If both the patient and physician agree that now there is no palpable abnormality, reassessment in 2 months to reconfirm is advisable.
Breast pain is common and rarely indicates dangerous pathology. It may be unilateral or bilateral, intermittent or persistent, sharp or aching. Only half of women with significant breast pain seek medical attention. Cancer uncommonly presents with breast pain, and mastalgia is not an indication for a diagnostic mammogram. Focal persistent pain may be associated with cancer in 1% to 3% of patients, but primarily in younger women seen at a tertiary care center. If focal persistent pain is concerning, a diagnostic mammogram and ultrasound can adequately rule out cancer, or the patient may be referred.
Pain sources intrinsic to the breast include fibrocystic disease, duct ectasia, trauma, sclerosing adenosis, and stretching of Cooper ligaments. Conditions external to the breast but perceived as breast pain include costochondritis (Tietze syndrome), cervical radiculopathy, intercostal neuralgia, thrombophlebitis of the thoracoepigastric vein (Mondor disease), herpes zoster, angina, cholecystitis, and hiatal hernia. Palpate the breast bimanually to differentiate breast from chest wall pain. If findings are negative and mammographic screening is current, the patient can be offered reassurance and/or analgesics. Interference with activities such as hugging, exercising, and sleeping may indicate a need for more aggressive pain management, starting with a well-fitted brassiere with good support. Caffeine reduction is not likely beneficial. Pharmacologic agents for mastalgia are not without side effects. If needed, however, tamoxifen is one of the top considerations.
Breasts are secretory organs. Important nipple discharge characteristics are whether it is spontaneous or expressed, unilateral or bilateral, involving single or multiple ducts, and the color. The examiner should try to elicit discharge palpating each breast quadrant from the outside toward the areola, and then gently squeezing the areola. A mass should be ruled out, particularly under the areola. Whereas unilateral, single-duct, spontaneous, bloody or watery discharge is more concerning for neoplasia, bilateral, expressed, nonbloody discharge from multiple ducts is not associated with cancer. Consultation should be obtained for all bloody or recurrent spontaneous discharge. A thick grumous or purulent discharge may indicate duct ectasia (dilated lactiferous ducts with inspissated secretions) or subareolar abscess. Duct ectasia is also the most common cause of blood-stained discharge from multiple ducts. Duct ectasia is benign, but may be excised to rule out underlying cancer. Hyperprolactinemia is rare in older women. A serum prolactin is indicated if galactorrhea is observed or suspected, but is not necessary in most cases. Eczematous and other skin conditions may imitate nipple discharge.
Inflammatory conditions intrinsic to the breast include duct ectasia, fat necrosis, ruptured inflammatory cyst, inflammatory abscess due to obstructed ducts, idiopathic granulomatous mastitis, foreign body, radiation, and inflammatory carcinoma. Smoking, diabetes, and rheumatoid arthritis predispose to abscesses. The most common pathogen is Staphylococcus aureus. Risk factors for methicillin-resistant S aureus include diabetes and residence in long-term care. Most abscesses respond well to drainage and antibiotics. Conditions extrinsic to the breast that may present with inflammation include metastatic lung cancer, Wegener granulomatosis, sarcoidosis, and other skin diseases.
Perceived “pelvic” pain may arise from any component between the umbilicus and the upper thigh. Bladder pain including interstitial cystitis (IC) is discussed later in this chapter. A strictly gynecologic cause of either acute or chronic pelvic pain is uncommon in older women except with advanced malignancy. Although many women fear that the pain indicates an ovarian problem, other causes are more likely. The ovaries have shrunk to the size of an almond in its shell and are largely inactive, making painful cysts rare and torsion highly unlikely. Benign ovarian cysts and masses are usually asymptomatic until they are quite large. A complaint of “pain” is not likely to herald a gynecologic malignancy; nonspecific abdominal and pelvic discomfort are more common descriptions with cancer. Infection and neoplasm could be gynecologic causes of acute pain. But a nongynecologic cause would be more likely, such as constipation, diverticulitis, herpes zoster, or pelvic insufficiency fracture.
Anecdotally, older women rarely experience the same type of chronic pelvic pain (≥ 6 months) that plagues women in their reproductive years, with “cross-talk” between pelvic organ structures, pelvic tension myalgia, and central sensitization. POP may cause low back or low pelvic pain. Pelvic floor repair with synthetic mesh may result in chronic pain, usually remediable. More likely etiologies of chronic pelvic pain involve the gastrointestinal and musculoskeletal systems. The abdomen, low back, and hips should be evaluated. Myofascial pain with trigger points in the lower abdomen is a particularly notorious pelvic pain impostor. This occurs in 30% of patients with chronic abdominal pain, frequently misrepresented as visceral or functional pain. A finding of myofascial trigger points with Carnett test (increased point tenderness with partial sit-up tensing the abdominal muscles) does not completely rule out internal causes of pain, but initial treatment of this will clarify the etiology.
Following evaluation of the abdomen, back, bony pelvis, and hips, the pelvic examination should proceed slowly, assessing tenderness from external to internal. Urethra, bladder, and pelvic musculature can be sequentially palpated. If abdominal pain or tenderness is present, begin the “bimanual” examination of the uterus and ovaries using only the vaginal hand. After assessing cervical, uterine, and adnexal tenderness without abdominal palpation, then proceed to bimanual evaluation. If the cause is unknown, repeating the examination at subsequent visits is valuable, as the findings typically vary somewhat. Vulvovaginal pain examination is addressed below.
VULVAR AND VAGINAL ISSUES
Normal vulvar architecture consists of definite labia minora, labia majora, clitoris, clitoral hood, and intact urethral meatus (Figure 42-2). Advanced age and estrogen deficiency may lead to a nonpathologic loss of vulvar architecture, especially of the labia minora. Cherry angiomata and epithelial inclusion cysts on the labia majora are common and not concerning. Asymmetrical pigmented lesions should be noted and considered for either biopsy or follow-up examinations. Punch biopsies of the vulva are simple and rarely become infected. Bartholin glands are located in the inferior (dorsal) aspect of each labium majus. An asymptomatic Bartholin cyst does not require referral if there is no detectable mass associated with the cyst, but rare Bartholin gland malignancies do occur. A new swelling in an older woman is suspicious.
Illustration of pelvic examination landmarks and a urethral caruncle.
Benign Conditions of the Vulva
The hundreds of benign vulvar disorders generally fall into categories of infection, neoplasia, and dermatosis, some of which may reflect systemic disorders. Inflammatory disorders may be difficult to recognize, even by dermatologists, because the warm, moist, frictional environment alters their otherwise typical appearance. Establishing a nomenclature that is both clinically useful and pathologically appropriate is challenging. Furthermore, as Lynch et al. aptly stated, “Nomenclature regarding the eczematous and lichenified diseases is particularly confusing and controversial.” The current International Society for the Study of Vulvar Diseases classification relies primarily on histologic morphology (Table 42-2). Realizing its limitations, they have since formulated an approach that allows highly accurate diagnoses with just clinical observations. Estrogen deficiency may increase susceptibility to trauma, irritation, and secondary infection, but is not a primary cause of vulvar problems.
TABLE 42-2CLASSIFICATION OF VULVAR DERMATOSES: PATHOLOGIC SUBSETS AND CLINICAL CORRELATES (2006 INTERNATIONAL SOCIETY FOR THE STUDY OF VULVOVAGINAL DISEASE CLASSIFICATION) ||Download (.pdf) TABLE 42-2 CLASSIFICATION OF VULVAR DERMATOSES: PATHOLOGIC SUBSETS AND CLINICAL CORRELATES (2006 INTERNATIONAL SOCIETY FOR THE STUDY OF VULVOVAGINAL DISEASE CLASSIFICATION)
Allergic contact dermatitis
Irritant contact dermatitis
Acanthotic pattern (formerly squamous cell hyperplasia)
Lichen simplex chronicus
Secondary (superimposed on lichen sclerosus, lichen planus, or other)
Dermal homogenization/sclerosus pattern
Pemphigoid, cicatricial type
Linear IgA disease
Papular genitocrural acantholysis
Plasma cell vulvitis
Another term for vulvar dermatitis is vulvar eczema, the most common vulvar dermatosis. Hallmarks are pruritus (often disrupting sleep), scaling, and lichenification. Vulvar architecture is usually normal. When this occurs on previously normal skin, it is termed lichen simplex chronicus, formerly squamous hyperplasia. Lichenification can also occur where there is an underlying dermatologic disorder such as lichen sclerosus or psoriasis.
Vulvar dermatitis can be endogenous or exogenous. Endogenous refers to atopic dermatitis of the vulva, usually with a familial predisposition and extragenital occurrence of eczema. Exogenous vulvar dermatitis is more common in older adults, also called contact dermatitis. It may be initiated by irritants (80%) or allergens (20%). Vulvar epithelium is more vulnerable to irritants than other body areas. All soaps, feminine hygiene products, topical medications, urine, incontinence pads, and synthetic underwear are potential culprits. Effective treatment requires identifying and eliminating offending factors and applying topical anti-inflammatories. As a general rule, ointments are preferred to creams, because they are less prone to cause further irritation. Secondary infections with yeast and bacteria should be considered. When symptoms have resolved, a daily protective barrier cream or ointment may be necessary, such as when a patient cannot forgo incontinence products. Solid vegetable or mineral oil are among the least irritating.
Other Inflammatory Dermatoses of the Vulva
Lichen sclerosus is a chronic inflammatory disease that can occur at any age, its highest prevalence being after menopause. It may have an autoimmune etiology and is frequently associated with other autoimmune disorders. Pruritus is characteristic, but it may be asymptomatic. Typical lesions are porcelain white papules and plaques, often with areas of ecchymosis or purpura. Perianal involvement can create the classic “figure of eight” appearance. In more advanced cases, vulvar architecture is lost, with labial fusion, clitoral hood phimosis, and fissures. Scarring may lead to introital narrowing. The malignant potential of lichen sclerosus is debated, but may be as high as 4% to 5%. Biopsy confirmation of the diagnosis and visual inspection at least annually are advisable. Treatment is necessary only to control symptoms. Typical regimens involve potent topical glucocorticoids for a few weeks, then tapering to a lower dosing frequency. A subsequent maintenance regimen of daily or twice-daily emollient probably reduces the frequency of symptomatic flares. Estrogen has little or no effect on lichen sclerosus but can improve the resilience of unaffected areas, and estrogen cream can serve as an emollient.
Lichen planus exhibits a wide range of morphologies. Of women with oral lichen planus, approximately 20% to 25% have vulvovaginal lesions. The erosive form may cause pain and vaginal discharge, and lead to agglutination and resorption of labial architecture, rarely with complete obliteration of the vaginal orifice. Other autoimmune disorders to consider are Zoon disorder (plasma cell vulvitis), Behçet disease, Crohn disease, aphthous ulcers, and Hailey-Hailey disorder (fragile and inflamed vulvar and axillary skin). Psoriatic lesions of the genitalia do not exhibit the silver appearance seen elsewhere on the body, and are more often simply erythematous. There is usually a personal or family history of psoriasis.
Ulcerations and Infections of the Vulva
The differential diagnosis of genital ulceration includes sexually transmitted diseases, the most common of which in United States is herpes simplex virus (HSV). Immune suppression, including very advanced age, is a risk factor for HSV infection in the absence of sexual contact, and for herpes zoster of the S3 dermatome. A primary infection is usually accompanied by lymphadenopathy, vaginal discharge, urinary frequency and urgency, and painful ulcers on the labia and/or cervix. Zoster can inhibit detrusor function resulting in an inability to void. Lesions clear more quickly with antiviral agents. Other causes include syphilis, the autoimmune disorders listed above, blistering dermatologic disorders and, of particular concern in older women, excoriated or ulcerated neoplasia.
Vulvar intraepithelial neoplasia (VIN) is now divided into two types. Usual-type VIN associated with human papilloma virus (HPV) occurs mainly in younger women. Differentiated or simplex type classically occurs in postmenopausal women with chronic skin conditions (lichen sclerosus, lichen simplex chronicus). Differentiated VIN has a higher malignant potential, but both types may progress to squamous cell cancer (SCC). Pruritus is the most common symptom. VIN lesions cannot be reliably distinguished by inspection alone. Any focal, raised, irregular, or pigmented lesion warrants biopsy. Of these, pigmentation is the most difficult to interpret, possibly requiring surveillance over time.
Vulvar cancer (Table 42-3) is the fourth most common malignancy of the female genital tract, with 3400 new cases reported annually in the United States. SCC is the most common type, and malignant melanoma a distant second. The incidence of both types of SCC (with and without HPV) rises steadily with age, reaching 12 to 20 per 100,000 in the ninth decade. HPV is associated with 15% to 50% of vulvar cancers in older women. For unclear reasons, the incidence of vulvar SCC in the United States and Canada is rising in all age groups over 40 and the 5-year relative survival is declining. These trends become more pronounced in each successive age group. Between 1992 and 2008 in women aged greater than or equal to 80, the 2-year relative survival decreased 10% and the 5-year relative survival declined over 15%. These alarming statistics are all the more disturbing because research has been limited and the causes are not well understood. Pruritus, pain, and a palpable lesion are typical presenting complaints. Malignant melanoma is rare. Concerning characteristics are the same as in sun-exposed skin. Mainstays of therapy for vulvar cancer treatment are radical vulvectomy with inguinal lymphadenectomy, radiation, and chemotherapy. Wide local excision may suffice for some early cancers and may be used for palliation in frail women.
TABLE 42-3ESTIMATED 5-YEAR GYNECOLOGIC CANCER SURVIVAL BY DISEASE STAGE ||Download (.pdf) TABLE 42-3 ESTIMATED 5-YEAR GYNECOLOGIC CANCER SURVIVAL BY DISEASE STAGE
|CANCER TYPE ||STAGE I ||STAGE II ||STAGE III ||STAGE IV |
|Endometrial ||54%–88% ||40%–76% ||22%–57% ||12%–18% |
|Ovarian ||80%–90% ||65%–70% ||30%–59% ||17% |
|Cervical ||80%–95% ||74%–77% ||46%–52% ||20%–29% |
|Vulvar ||85% ||69% ||40% ||22% |
|Vaginal ||74% ||50% ||32% ||0%–18% |
Vulvar Pain, Vaginal Pain, and Dyspareunia
To evaluate vulvar or vaginal pain, the perineum from the mons pubis to the anus should be meticulously inspected for vulvar architectural changes, which may or may not be pathologic, including fissures, ulcers, erythema, and other signs of inflammation. Palpation of the vulva and around the vaginal introitus with a cotton swab or other narrow instrument will better establish the location and extent of tenderness than digital palpation. Particular areas to assess are the base of hymeneal remnants, posterior fourchette, and periurethral Skene glands.
Vulvar pain in the absence of any clinically identifiable condition is now called simply vulvodynia. It may be provoked, unprovoked, or both, and generalized or localized. “Localized provoked vulvodynia” denotes the condition formerly termed vulvar vestibulitis. The suffix “itis” is technically inaccurate, since inflammation is not usually present. Pain located specifically in the vestibule may be called vestibulodynia. This is not particularly common with aging or atrophy. The condition is frustrating, poorly understood, and difficult to treat. Neuropathy is thought to be one of the many components. Estrogen and/or glucocorticoid topical preparations rarely improve symptoms. Daily to twice-daily solid mineral or vegetable oil may provide relief over time by protecting from irritants. Neuromodulators used for chronic pain may be beneficial. Herpes zoster and postherpetic neuralgia should be considered in unilateral cases.
Unlike the vulva, the vagina is rarely an isolated source of pain unless the patient is sexually active. Simple postmenopausal vaginal atrophy is usually asymptomatic, but dyspareunia is common. Dyspareunia evaluation is guided by historical factors such as past sexual experiences, exact symptoms during intercourse, and examination. The anterior, lateral, and posterior vaginal walls and apex should be inspected and palpated as separately as possible. Atrophic vaginitis considerations are presented below. Patients with “atrophic vaginitis” that has not responded to estrogen frequently have an unrecognized vulvar condition. Isolated vaginal pain in the absence of intercourse should prompt consideration of surrounding organs and structures.
Vaginitis, Vaginosis, and Vaginal Discharge
Symptoms of vaginitis, vaginosis, and vaginal discharge overlap with each other and with those of vulvar conditions. A true bacterial vaginitis is uncommon in the absence of an underlying epithelial disorder. Bacterial vaginosis incidence increases with age, but only requires treatment for bothersome symptoms or planned vaginal surgery. Yeast infection incidence declines with age, but antibiotics, diabetes, immune suppression, and estrogen therapy are risk factors. Trichomonas can be carried asymptomatically for at least 3 months, but eventually becomes symptomatic. Coexistence with bacterial vaginosis is common. Either estrogen initiation or replacement of a large vaginal prolapse with a pessary may cause benign white discharge in the first few months from an increase in epithelial turnover. Desquamative inflammatory vaginitis is an uncommon cause of discharge, burning, and dyspareunia, and may be a manifestation of erosive lichen planus. Rare causes of purulent malodorous discharge include an enterovaginal fistula secondary to diverticulitis and bacterial endometritis.
Evaluation in younger and older women is largely the same except for vaginal bleeding. Any history of a brown or red color necessitates endometrial evaluation. Physical examination is essential to evaluate vaginal discharge, because definitive description is difficult for anyone. Findings often differ from the presumption based on history. However, when symptoms are classic for yeast infection and follow-up is likely, a trial of antifungal treatment prior to examination is reasonable. Potassium hydroxide and normal saline wet mounts plus pH paper are the usual evaluation tools, but useful triage information is gleaned even without them. With aging and estrogen deficiency vaginal pH rises, so that a higher pH (> 4.5) is less indicative of bacterial vaginosis, but a low pH may help identify a yeast infection. If microscopy is not available, commercial tests are available for bacterial vaginosis and Trichomonas vaginalis, and yeast can be cultured. A trichomoniasis diagnosis should prompt sexually transmitted infection screening and treatment of partner(s). Current recommendations for detection and treatment of sexually transmitted diseases are maintained on the website of the Centers for Disease Control and Prevention (www.cdc.gov/std/default.htm).
Vaginal atrophy secondary to hypoestrinism involves several changes including mucosal thinning; loss of rugae, elasticity, and distensibility; an increase in subepithelial connective tissue and vaginal pH (> 4.5); and reduced secretions. Changes in the vaginal microbiome predispose to urinary tract infections, but traditional assumptions about specific organisms such as lactobacilli are changing and not yet clarified. Atrophic “vaginitis” is poorly defined apart from simple atrophy, but is usually diagnosed when symptoms (dryness, itching, irritation, burning, dyspareunia, irritative voiding) or signs (pale, thin, shiny vaginal mucosa, telangiectasias, petechiae, patches of inflammation, discharge) are present (Figure 42-3). A cytologic maturation index would reveal 60% to 100% parabasal cells, but is not necessary for the diagnosis.
Illustration of atrophic vaginitis versus normal mucosa. Signs of atrophic vaginitis may include pale, smooth, shiny mucosa with patches of inflammation and petechiae.
Low-dose topical estrogen remains the preferred treatment for atrophic vaginitis in most women. It is the most proven for symptom relief, and there are several delivery options, via ring, tablet, or cream. The ring can remain in the vagina for 3 months without being removed, releasing 6 to 9 μg of estradiol daily. Tablets containing 10 μg of estradiol are inserted nightly for 2 weeks, then twice a week. Daily use is required initially to stimulate mucosal remodeling, because the very low maintenance dose alone is not sufficient. The dose and absorption of both the ring and the tablet are specific and well studied. Serum estradiol rises briefly in the first 24 hours then remains within the postmenopausal range.
Exact low dosage is difficult to achieve with creams, but cream has other advantages. The vehicle soothes the mucosa. Creams are often the least costly approach. The amounts needed to treat atrophic vaginitis are smaller than the lowest measurements on the applicator; using an estimated 1/4 to 1/2 g twice weekly is reasonable. Some women find fingertip application of a pea- or chocolate chip–size amount at the introitus easier than inserting an applicator.
Vaginal estrogen use in breast cancer survivors is controversial and best prescribed in consultation with an oncologist. Estrogen is contraindicated during breast cancer treatment, but no harm has been detected from use of low-dose topical preparations in survivors. Patients taking aromatase inhibitors may achieve undesirably high premenopausal serum estrogen levels, warranting extra precaution or consultation before and during any estrogen treatment. Concerns seem to only apply to hormone-sensitive cancers. No increased recurrence of hormone receptor negative cancers has been found with any type of postmenopausal hormone therapy. Nonetheless, survivors should try nonhormonal vaginal moisturizers first, then if necessary estrogen tablets or ring so a controlled dose can be given.
With these low doses, progestins to prevent endometrial hyperplasia are not required. However, estrogen absorption varies considerably between individuals, and endometrial growth could possibly be stimulated. Any brown or red discharge necessitates evaluation of the endometrium (see below). Occasionally it may be useful to investigate whether estrogen is causing endometrial growth. The simplest and cheapest method is to prescribe medroxyprogesterone acetate 5 mg or similar progestin for 12 days, to see whether she has “withdrawal bleeding” thereafter.
Ospemifene is an oral estrogen agonist/antagonist, or selective estrogen receptor modulator (SERM), indicated for atrophic vaginitis. It is effective for vulvovaginal atrophy, and appears to have favorable effects on bone, neutral effects on the endometrium and the cardiovascular system, and possibly favorable but as yet unknown effects on breast cancer risk. Long-term data are lacking. Risks and contraindications are similar to those for estrogen, including venous thromboembolism. Vasomotor symptoms are bothersome in 10% of patients.
Other nonestrogen therapies are less reliable in reducing dyspareunia and irritative voiding symptoms, but often relieve mild symptoms. Vaginal moisturizers are used on a regular basis, daily to weekly, to maintain epithelial moisture and vaginal pH. In addition, vaginal lubricants may be used for intercourse. Frequent sexual activity helps maintain supple tissues. Alternative hormonal agents (dehydroepiandrosterone, other SERMs, testosterone) are promising but not yet sufficiently studied.
Vaginal cancer accounts for 1% or less of female genital tract cancers. Metastatic disease of the vagina is more common than primary vaginal cancer, notably from cancers of the endometrium, cervix, vulva, ovary, breast, rectum, and kidney. The most common primary vaginal cancer is SCC, but adenocarcinoma, sarcoma, melanoma, and others occur. Vaginal SCC is often preceded by vaginal intraepithelial neoplasia, which is associated with concomitant cervical or vulvar neoplasia in about 50% of cases. It is usually asymptomatic and not easily visible, but induration may be palpable. Two-thirds of cases occur in the upper vagina. Risk factors for primary vaginal cancer are the same as those for cervical cancer, including prior gynecologic cancer and radiation therapy. Bleeding, discharge, pain, and urinary or rectal complaints are presenting symptoms. Survival drops precipitously beyond stage II (see Table 42-3).
Examination of the Cervix
The location of the squamocolumnar junction, the border between squamous (ectocervical) and mucous (endocervical) epithelia, changes location over a lifespan. It is usually within the endocervical canal in older women and not visible. Its importance lies in the fact that it is the most common site of cervical neoplasia. Cystic structures near this border are almost invariably nabothian cysts. These are not true cysts, but collections of mucus trapped during metaplastic transition, when squamous cells cover mucus-secreting crypts. They do not require biopsy. Any lesion whose benignity is uncertain should be biopsied or referred. Cytology alone is not an appropriate evaluation of an abnormality.
Cervical cancer is the third most common gynecologic malignancy diagnosed in the United States, but the most common one in developing nations. The risk of cervical cancer increases with age, and the case-fatality rate is higher in older women (see Table 42-3). While women over age 65 represent 14% of the US female population, 20% of new cervical cancer cases and 34% of cervical cancer deaths are in this group. Most of these are in unscreened or inadequately screened women. Three-fourths of cervical cancers are SCC. The remaining adeno-, adenosquamous, and clear cell carcinomas have higher mortality rates. In older women only half to two-thirds of cervical cancers are associated with HPV. Postcoital bleeding may occur at an early stage, but other symptoms (pain and bowel or bladder symptoms) are absent. Radical hysterectomy is the primary treatment for early-stage cervical cancer. Radiation therapy is used for locally advanced disease, as adjunctive treatment, when surgery is not an option, and along with chemotherapy for palliation.
Cervical Cancer Screening
The excess deaths from this mostly preventable malignancy are only avoided through screening, including “adequate” screening of older women. Screening older women provides equivalent benefit to screening younger women, that is, an equivalent reduction in severe cervical intraepithelial neoplasia (CIN) and, by inference, of cancer. But due to low cancer incidence and long lead time, routine screening after age 65 provides little benefit if women have been adequately screened prior to this. The key to safe discontinuation is knowing the patient’s screening and risk factor history. The three main issues in older women are (1) when to discontinue screening, (2) in whom to not discontinue screening, and until what point, and (3) the best screening modalities.
Cervical cancer screening has evolved from microscopy of exfoliated cells in the vagina to detect current cancer, introduced by Georgios Papanikolaou in 1928, to prevention of cancer through HPV genotyping, with or without cervical cytology. Testing options, recommendations, and guidelines have changed at a dizzying rate in recent years, and will continue to evolve. Experts are still debating optimum screening based on current techniques, and will need to further debate the improved methods for abnormality triage that are in development. HPV genotyping has not been studied enough in older women to abandon cytology, but “cotesting” with both HPV DNA and cytology is wise. HPV testing detects adenocarcinoma and its precursors better than cytology alone, and adenocarcinoma is relatively more frequent at older ages. Updated guidelines are available from the American Society for Colposcopy and Cervical Pathology (www.asccp.org).
ACOG and other organizations recommend discontinuing cervical screening after appropriate criteria are met. The patient should be age 65 or older, low risk, and have had adequate negative screening. Adequate is defined as three consecutive negative cervical cytology tests or two negative cotests in the past 10 years, the most recent of which was within the past 5 years. Ideally the final test would include HPV genotyping to minimize the chance of adenocarcinoma, but this is not a specific recommendation. Women older than 65 should continue with screening until these criteria are met. Having a new sexual partner does not necessitate additional screening.
Screening of women who have undergone a total hysterectomy (corpus et cervix uteri) is not recommended unless the hysterectomy was performed for cancer or the woman is a DES daughter. The positive predictive value of vaginal cuff cytology after hysterectomy for benign disease is approximately zero. Many women do not know whether their hysterectomy was total or supracervical (corpus alone). This can be determined at the initial pelvic examination. If a cervix is unexpectedly discovered, adequate screening should be performed before discontinuation.
It may be premature to recommend against screening a population with a much higher case-fatality rate. A case-control study estimated that 36% of cervical cancer deaths in women 55 to 79 years old could have been avoided by screening. Cervical cancer screening discontinuation guidelines are based on public health statistical modeling and cost concerns. As such, they do not necessarily apply in all cases. Discontinuation at any age because of medical issues is appropriate. Likewise, continued screening in concerned individuals is medically appropriate, albeit with a greater chance for unnecessary interventions than for benefit. Symptom investigation is not equivalent to screening. Although neither cytology nor HPV genotyping sufficiently evaluates signs or symptoms, these tests are appropriate as part of the initial evaluation.
Risk factors for cervical cancer include an abnormal Pap smear within the past decade, a history of moderate or severe CIN (CIN 2 or 3) within the past 20 years; a history of cervical, vaginal, or vulvar cancer; immune suppression; and DES exposure in utero. These groups are excluded from major society guidelines for lengthening screening intervals and discontinuation, but without sufficient alternative recommendations. Annual screening should continue for at least 20 years following successful treatment for CIN 2+. Women infected with human immunodeficiency virus (HIV) should continue annual screening indefinitely. Other causes of immune suppression including solid organ transplant, autoimmune disorders, treatment with glucocorticoids, and chronic antineoplastic therapies are not addressed. The relevance of DES exposure in utero to cervical or vaginal cancer risk in advanced age is uncertain. Although ACOG recommends continuing annual internal pelvic examinations indefinitely in DES daughters, it does not specifically address cervical or vaginal cytology.
CORPUS UTERI AND VAGINAL BLEEDING
Benign Conditions of the Uterus
Both the uterus and leiomyomata (fibroids) shrink after menopause. A palpably large uterus (navel orange or grapefruit sized) is unusual. Previous medical records would probably clarify whether this is a new finding. If unclear, sonographic evaluation would inform the need for further evaluation. Uterine tenderness is also unusual. Bacterial endometritis is uncommon, but occurs even in the absence of uterine manipulation. It is usually associated with a purulent, odorous discharge and/or bleeding.
Ninety percent of uterine cancers originate in the endometrium. Endometrial cancer is the most common gynecologic malignancy in developed countries and the second most common in developing countries. It accounts for 7% of all cancers in women in the United States. The mortality rate has been declining slowly, but more than 10,000 women still die annually in the United States of this disease (see Table 42-3). Incidence rates in Europe and North America have risen since the 1980s, possibly related to increases in obesity and life expectancy with a concomitant decrease in birth rates. Three-fourths are type I, endometrioid adenocarcinoma. Type II is more aggressive and characterized by clear cell and papillary serous tumor histologies. Papillary serous carcinoma accounts for only 10% of uterine cancers but 40% of uterine cancer deaths.
Type I endometrial cancer is associated with traditional risk factors related to estrogen abundance and inadequate progestin. It tends to present at an earlier stage and younger age than does type II. Risk factors include early menarche and late menopause, obesity, chronic anovulation, type 2 diabetes, hypertension, and nulliparity. Pregnancy, lactation, hormonal contraceptives (including a progesterone-releasing intrauterine device), and postmenopausal hormone therapy with continuous (not intermittent) progestins are protective historical factors. Pathogenesis and risk factors for type II endometrial cancer are less well understood. Although the effect size of risk and protective factors is stronger in most studies for type I cancer than for type II, the factors are surprisingly similar. Risk factors include body mass index, early menarche, and diabetes; protective factors are higher parity, oral contraceptive use, and cigarette smoking.
Endometrial cancer is the most common sentinel cancer in Lynch syndrome, an autosomal dominant condition caused by germline mutations in mismatch repair genes. Lynch syndrome accounts for 2% to 5% of endometrial cancers and is more associated with younger age and type I histomorphology, but not reliably so. The question of universal versus selective genetic screening in endometrial cancer patients remains to be resolved. The 2014 Society for Gynecologic Oncology recommends that “all women who are diagnosed with endometrial cancer should undergo systematic clinical screening for Lynch syndrome (review of personal and family history) and/or molecular screening. Molecular screening of endometrial cancers for Lynch syndrome is the preferred strategy when resources are available.”
Interest in endometrial cancer prevention is growing, centering on interventions for obesity and diabetes, such as lifestyle changes and use of metformin. Metformin may directly inhibit endometrial cancer cell proliferation in addition to its other benefits. Progestins could theoretically prevent many endometrial cancers in obese women, but this has not yet been adequately studied. As obesity prevalence peaks in the 65 to 74 year age range, geriatrics practitioners will likely become key in endometrial cancer prevention strategies.
A hysterectomy with bilateral salpingo-oophorectomy, lymph node sampling, and tumor debulking is required for endometrial cancer staging and is the mainstay of treatment. Radiation and/or chemotherapy may be used adjunctively or in women who are too frail to undergo surgery. Overall 5-year survival is estimated at 82%, since bleeding usually leads to early diagnosis. Older age is associated with a worse prognosis because more aggressive tumors are relatively more common, as well as due to comorbidity, late diagnosis, and lack of aggressive treatment.
Malignant lesions of the myometrium include leiomyosarcoma and other sarcomatoid tumors. These do not typically cause bleeding in early stages, and may only be detected by the presence of an enlarging uterus or pelvic mass, or be discovered after hysterectomy. Incidence of leiomyosarcoma peaks in the sixth and seventh decades. They are aggressive tumors with high metastatic potential. Treatment involves surgery, chemotherapy, and radiation. Extension of tumor beyond the confines of the uterus is associated with a poor prognosis.
Approach to Vaginal Bleeding
Abnormal vaginal bleeding occurs in up to 20% of postmenopausal women, 10% to 20% of the time due to endometrial hyperplasia or neoplasia. Studies invariably analyze “postmenopausal” as one group, so these statistics misrepresent the risks in older women. Older women bleed less often, but older age increases the risk of malignancy and of a higher-grade cancer. Although most women with postmenopausal bleeding will be referred to a gynecologist, a focused history and examination will ensure the best referral. A rectal polyp, urethral mucosal prolapse, or neglected pessary may be discovered.
All pelvic bleeding sources should be screened out, including hematuria, hematochezia, vulvovaginal pathology, and trauma (Table 42-4). Examination generally begins with the breast and abdomen, including axillary, supra- and infraclavicular, and inguinal lymph nodes. External genitalia, vagina, and cervix are inspected for ulcerations, atrophy, abrasions, polyps, etc. If the cervix appears normal, cancer screening with both cytology and HPV genotyping is advisable unless recently performed. Bimanual and rectal examinations will help rule out pelvic masses, tissue induration, and rectal pathology.
TABLE 42-4DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN OLDER WOMEN ||Download (.pdf) TABLE 42-4 DIFFERENTIAL DIAGNOSIS OF VAGINAL BLEEDING IN OLDER WOMEN
Endometrial proliferation from estrogen stimulation
|Vagina || |
Prolapse with abrasion
|Vulva || |
|Urinary tract || |
Urethral mucosal prolapse
|Gastrointestinal tract || |
|Other (rare causes) || |
Metastatic nongynecologic cancer
|Systemic illness || |
|Iatrogenic || |
Regardless of other findings, the endometrium must be evaluated with a biopsy or transvaginal ultrasound. Office biopsy can have greater than 99% sensitivity, but not all devices achieve this. Sonographic sensitivity depends on whether a 3-, 4-, or 5-mm endometrial thickness is used to define abnormal, which then requires biopsy. Defining greater than 5 mm as abnormal can miss up to 10% of cancers. Lowering the acceptable thickness to 3 mm or less increases sensitivity to 98%. ACOG recommends against proceeding immediately to biopsy at an intermediate cutoff of 4 mm or less. At any cutoff level, the cancers missed tend to be the more aggressive type II, for which age is a risk factor. Therefore a biopsy for tissue diagnosis is preferable to sonography to evaluate the endometrium in older women. Persistent or recurrent bleeding requires a more thorough evaluation without delay.
No guidelines have been established for the evaluation of vaginal bleeding in frail, impaired older women. Even if aggressive treatments are not an option, palliative management improves when the disease process is understood. Evaluation of vaginal bleeding including biopsy can always be recommended, guided by clinical judgement and the patient’s wishes.
Benign Conditions of the Ovary
Menopause occurs when the ovary ceases its cyclic reproductive function and shrinks to an average volume of less than 4 cm3. It continues to be an important source of androgen production, but not of estrogen. Functional cysts, normally associated with development of mature ova, still occur fairly often after menopause. These generally resolve without intervention. Benign lesions are overwhelmingly epithelial tumors, usually cystadenomas. Tumors may also arise from stromal or germ cells, but most of these occur at younger ages. An endometrioma may persist indefinitely, but is unlikely to grow or become newly symptomatic in older women.
Each year 22,000 women in the United States are diagnosed with epithelial ovarian cancer and 15,500 women die of this disease. The median age at diagnosis is 63. The age-specific incidence peaks at age 80 to 84, and subsequently plateaus. Survival rates are poor primarily because of diagnosis at late stages (see Table 42-3). Initial symptoms are nonspecific, such as abdominal or pelvic pain, bloating, urinary complaints, and constipation. It is now appreciated that early-stage cancers are often symptomatic. In retrospect, most ovarian cancer patients have had symptoms for several months prior to diagnosis. While a transvaginal ultrasound and CA-125 blood test perform poorly as screening tests in low-risk women, they are useful to rule out ovarian cancer when abdominal, pelvic, gastrointestinal, or urinary symptoms are present. Early evaluation of symptoms has not been proven to improve survival, but some evidence suggests it identifies more women with completely resectable disease. Genetic testing is evolving rapidly. It is now thought that approximately 25% of ovarian cancers have a germline mutation.
The vast majority of ovarian malignancies in older women are epithelial. The paradigm of epithelial ovarian cancer pathogenesis has undergone radical changes in the past decade. Rather than arising from the ovarian cortex, most cancers are likely derived from the fallopian tube or the endometrium. Epithelial ovarian cancers are now divided into two broad categories. The relatively indolent type I tumors are comprised of low-grade serous, low-grade endometrioid, clear cell, and mucinous carcinomas, and Brenner tumors. Type II tumors are high-grade serous, high-grade endometrioid, and other aggressive carcinomas. While these new distinctions have few direct implications for geriatrics practice, they have expanded preventive surgical strategies. ACOG recommends performing incidental bilateral salpingectomy whenever possible. Older women already routinely undergo bilateral salpingo-oophorectomy incidental to abdominal hysterectomy, but not routinely during vaginal surgery. This should be considered in preoperative planning, but no data inform the decision.
Surgery is indicated for most women with ovarian cancer, even in advanced age, both for staging and improved survival with optimal tumor debulking. Treatment outcomes are better on average when the initial surgery is performed by a gynecologic oncologist rather than a general gynecologist, due to more complete staging and debulking. Having one surgery for diagnosis and partial treatment, then a subsequent one to finish the staging and treatment is associated with worse outcomes. This may have implications for referrals from a geriatrics practice.
“Adnexa” is a plural word meaning “parts.” Adnexa uteri refers to the fallopian tube and ovary. Adnexal masses can be, accordingly, of either the tube or ovary, but many other gynecologic and nongynecologic pathologies masquerade as adnexal masses. Diagnosis of an ovarian mass requires excisional surgery, as any biopsy risks seeding the peritoneal cavity and needle track. However, imaging can obviate surgery in the majority of patients. Although the chance of malignancy is increased after menopause, most adnexal masses are benign.
Transvaginal ultrasound is the preferred imaging study for adnexal masses. Magnetic resonance imaging (MRI) is best suited to clarify the malignant potential if ultrasound is unreliable or cannot be performed transvaginally. When extraovarian disease is suspected or needs to be ruled out, computed tomography (CT) scan is the most reliable technique. Ultrasonography may be useful even when the adnexal mass was discovered on another imaging study, sometimes adding information that better characterizes the ovaries and uterus. For cysts that will be followed, it is best to measure size over time with the same imaging modality, and ultrasound is less expensive.
Simple cysts less than 10-cm diameter will resolve spontaneously in half of older patients, indicating they were functional cysts. Most of the persistent ones eventually excised are benign epithelial tumors. Complex ovarian masses, with loculations or solid components, comprise 3% of postmenopausal adnexal masses. These are more concerning for neoplasia, but up to half may also resolve spontaneously. If an asymptomatic simple cyst is smaller than 10-cm diameter on transvaginal ultrasound and the serum CA-125 is not elevated, the usual plan is to repeat these studies in 3 to 6 months. Indications for urgent gynecologic consultation include size greater than or equal to 10 cm, complex components, or an elevated CA-125.
Hormone Replacement Therapy
Estrogen and estrogen plus progestin hormone replacement therapy (HT) following menopause has a complex constellation of statistically small risks, mostly outweighed by other risk and protective factors, and benefits, which can usually be managed with nonhormonal alternatives. While initiation of HT after age 65 is contraindicated, continuation of HT taken since menopause must be decided on an individual basis. The major professional society recommendations that “Even though short-term use of hormone therapy may be useful for menopausal symptom relief, such as for vasomotor instability, long-term use of hormone therapy for chronic disease prevention is not warranted” does not inform management in the majority of older women still taking HT. In health-conscious women, the marginal risk of continuation is very small. However, given the association with stroke and cardiovascular events, most women over age 65 will choose to discontinue HT. The issue then becomes how to discontinue without suffering excessive menopausal symptoms.
Four randomized trials studying fewer than 300 women have evaluated abrupt discontinuation versus tapering over 2 weeks, 4 weeks, 4 months, and 6 months. Overall successful discontinuation rates were similar, but symptoms were generally greater in the abrupt groups. Roughly half of women tolerate sudden cessation, but do better with ongoing clinical support for up to 3 years. Others experience unacceptable vasomotor symptoms, insomnia, irritability, short-term memory loss, or fatigue and resume HT. Anecdotally, tapering over an even longer time would effect greater success with fewer symptoms. Unless urgent, this can be done as slowly as necessary, reducing the dose every few months or annually. When the lowest commercially available dose has been reached, the taper can be continued dropping one weekly dose at a time, once a month or as tolerated. Vasomotor symptoms can be ameliorated with progestins, neuromodulating medications, low-dose vaginal estrogens, and a few other medications.
Occasionally an older woman not taking estrogen experiences new-onset vasomotor symptoms. Pertinent history includes onset, frequency, duration, timing during the day or night, facial erythema, perspiration, flushed feelings, associated activities, and her symptoms at the time of menopause. Medications or supplements are often the culprit. While hormone-related vasomotor symptoms do not suddenly arise years after a decline in estrogen, it is unclear in some cases whether hormones could be involved. A trial of estrogen therapy for 1 to 3 months can be informative or educational. Transdermal administration would minimize the risk of a vascular event.
UROGYNECOLOGIC AND PELVIC FLOOR SUPPORT ISSUES
A variety of bladder and pelvic floor support disorders can occur in older adults. Urinary incontinence and urinary tract infections are among the most common. These are covered in more detail in Chapters 53 and 127, respectively. This section will focus on several specific conditions common in female urology and urogynecology including urethral disorders such as urethral caruncle, urethral cancer, urethral stricture, and urethral diverticulum; interstitial cystitis and painful bladder syndrome; and POP.
Several disorders of the female urethra occur with greater incidence and prevalence in older women compared to their younger counterparts. Urethral caruncle generally appears as a polypoid red mass protruding from the urethra at the 6 o’clock position. This is often asymptomatic and identified incidentally on physical examination. Some patients may notice it and are often concerned for possible malignancy. Urethral caruncles are typically soft to palpation, although they may bleed due to irritation. They represent a prolapse of the urethral mucosa with possible loss of support of the periurethral fascia. Topical estrogen is generally effective, and may lead to reduction in size or complete involution of the caruncle. In contrast, urethral cancers in women may present with bleeding and are typically hard or firm to palpation. The tumor can extend proximally toward the bladder neck, or into the vagina. Treatment is typically surgical, although radiation may also be used in select cases or for palliation.
Urethral strictures in women are uncommon. Surgical excision and reconstruction is the most effective form of therapy. Urethral dilation should be avoided in women and is not particularly effective for long-term therapy. There are no data to support routine urethral dilation for treatment of urinary tract infection or voiding dysfunction in most women. Urethral diverticulum results from an outpouching of tissue in the urethra in association with a defect in the midline fusion of the urethral plate. Women often experience the “3-Ds” of dysuria, dyspareunia, and dribbling incontinence. Surgical excision with urethral closure or reconstruction is typically indicated. Women with urethral diverticulum are at somewhat increased risk of urethral malignancy.
Interstitial Cystitis and Painful Bladder Syndrome
Interstitial cystitis (IC), sometimes called painful bladder syndrome (PBS), is a chronic condition of the bladder typically associated with a constellation of symptoms including urinary urgency, frequency, and pelvic pain. Patients generally experience worse pain with bladder filling, which is relieved at least temporarily by voiding. Pain is a hallmark symptom, and helps to differentiate the condition from overactive bladder (OAB) and other forms of lower urinary tract dysfunction. The exact etiology of IC is unknown although theories including autoimmune components, direct chemical irritants in the urine, effects from inflammatory mediators, and defects in the bladder epithelial barrier layer are known. Other conditions that should be considered in cases of possible IC include bladder cancer, bladder carcinoma in situ, urinary tract infection, and bladder stones. Continued symptoms in the context of persistent negative urine cultures should prompt the clinician to consider IC.
Diagnosis can be made on the basis of clinical symptoms. Cystoscopy with hydrodistension of the bladder under anesthesia is a useful diagnostic tool, and may also be therapeutic for many patients. Reduced bladder capacity and visual changes including petechial hemorrhage are commonly seen in cases of IC. Ulcerations of the bladder mucosa occur less commonly, but may represent more severe disease. Cystoscopy also offers the clinician the opportunity to visually examine the bladder to rule out other serious conditions such as bladder cancer, particularly in older women where the rates of bladder cancer increase compared to young women. Bladder wash cytology and biopsies may also be used to help aid in the diagnosis of bladder cancer. Patients may be treated for IC or PBS without cystoscopic confirmation of the condition, but in older patients it is wise to eliminate other potential pathologies.
Successful treatment of IC and PBS often requires multimodal therapy. Diet modification includes avoiding trigger foods and beverages including caffeine, carbonated drinks, alcohol, spicy and acid-rich foods, and tomatoes. Medical therapies include low-dose antihistamines, antispasmodics, and anticholinergic medications. Low-dose tricyclic antidepressant medications may be used for this purpose, but they should be used with caution in older women who may be at higher risk for side effects. Pentosan polysulfate is a low-molecular-weight heparin derivative that is administered orally. It is excreted in urine and helps to rebuild the glycosaminoglycan layer of the bladder. Instillation of medications inside the bladder including anti-inflammatory agents, heparin, lidocaine, and others can also be useful. Injection of botulinum toxin in the wall of the bladder for chemodenervation can be useful particularly for treatment of associated urinary urgency and frequency. The effect generally lasts for up to 9 to 12 months, and may need to be repeated at that time. Patients must understand the potential for urinary retention after this type of therapy, which could require clean intermittent catheterization at least temporarily. Surgical therapy with removal of the bladder is generally avoided because symptoms may recur even in the absence of the bladder.
Prolapse of the genital organs can be quite bothersome for older women. Incidence and prevalence rates of POP increase with advancing age. Risk factors include prior hysterectomy, obesity, smoking, and poor tissue quality. Several different types of prolapse occur depending on the involved anatomy. Patients may experience a bulging sensation from the vagina, or may complain of pressure or discomfort in the pelvis or lower back. Bleeding and discharge are also common symptoms, particularly in women with large prolapse extending out of the vaginal canal, and may be associated with erosion or ulceration of the vaginal mucosa.
Evaluation of Pelvic Organ Prolapse
Clinical evaluation includes careful history and physical examination (Table 42-5). Symptoms should be identified to help gauge the degree of bother experienced by the patient, which in turn can help determine the types of treatment that can be considered. In patients with little symptomatic bother and minimal other signs or symptoms, observation may be adequate. Careful pelvic examination is critical in making the correct diagnosis of POP. Prolapse of the anterior vaginal wall is a cystocele, and the posterior vaginal wall is typically a rectocele. Loss of support of the vaginal apex may include small bowel which is known as an enterocele. Uterine prolapse may also occur due to loss of support of the cardinal or uterosacral ligaments. Complete vaginal eversion may occur in women with a prior hysterectomy, or “procidentia” if the uterus is in situ.
TABLE 42-5EVALUATION AND MANAGEMENT OF PELVIC ORGAN PROLAPSE ||Download (.pdf) TABLE 42-5 EVALUATION AND MANAGEMENT OF PELVIC ORGAN PROLAPSE
Vaginal bulge, pressure or pain (often worse in late afternoon or evening)
Vaginal bleeding or discharge
Urinary frequency or incontinence
Difficulty initiating urinary stream
Sense of incomplete bladder emptying
Need to elevate the bladder to urinate or “splint” the perineum or rectum to defecate
Mucosal abrasions or ulcerations
Degree of descent of prolapse
Does prolapse extend beyond midpoint of vagina
Does prolapse extend beyond the vaginal introitus/hymenal ring
Does prolapse increase with maximal Valsalva or cough effort
Anterior vaginal wall, posterior vaginal wall, vaginal apex
Cervix and uterus—support and mobility
Urethra and bladder neck—support and mobility
Postvoid residual urine volume and urinalysis
Estrogen cream -to prevent and treat ulcerations and improve mucosal quality
Barrier creams or ointments to protect vaginal mucosa
Truss-strong elastic support
Uterosacral or sacrospinous ligament fixation of vaginal vault
Physical examination is important for complete assessment. On simple inspection, it can be difficult to differentiate the portion of the vagina involved in the prolapse. A single-blade speculum is useful for this purpose. The speculum is initially inserted to depress the posterior vaginal wall. The speculum is then reinserted in the reverse position to elevate the anterior vaginal wall allowing inspection of the posterior compartment for evidence of rectocele. Asking the patient to cough and Valsalva can help to demonstrate prolapse that may increase with abdominal straining. However, some older women cannot generate adequate pressure with this technique. It can be useful to also examine the patient in the standing position if possible, as some prolapse may only be evident with standing.
Cystocele occurs because of a weakness of the anterior vaginal wall fascia. The bladder descends into the space, and in some cases may protrude beyond the hymenal ring. Cystoceles may or may not be associated with stress urinary incontinence. Some women with large cystoceles may experience difficulty voiding due to angulation of the urethra or poor bladder contraction (Figure 42-4). In some cases, women with large cystoceles may report having to put their fingers in the vagina to elevate the tissue in order to straighten out the urethra to urinate. Despite this, high-grade obstruction in women is rare, and development of upper tract deterioration with hydronephrosis and renal insufficiency is uncommon. Hydroureter and hydronephrosis can occur if there is substantial ureteral kinking at the insertion into the bladder in cases of complete vaginal vault prolapse. This is more likely if the uterus is present. Serum blood urea nitrogen and creatinine level and renal ultrasound are useful in determining the extent of renal impairment.
Sagittal view of a cystocele. Note how a cystocele can cause angulation of the urethra and contribute to symptoms of voiding difficulty and urinary retention.
A rectocele is a protrusion of the rectum through the posterior wall of the vagina, and is caused by weakness in the perirectal fascia. Some patients may experience difficulty with defecation, including an increased sense of pressure or need to strain. Some women describe needing to “splint” or press on the posterior vaginal wall or perineum in order to completely evacuate their stool.
An enterocele is a herniation of small bowel and peritoneum through the apical vagina or between the uterosacral ligaments and rectovaginal space. It is the only true hernia among the various forms of POP. It is more common in women who have undergone prior hysterectomy. However, it can be present in any posterior vaginal wall prolapse, and rarely in anterior compartment prolapse.
Rectal prolapse involves protrusion of the rectum through the anal sphincter with tissue extending beyond the anal verge. It may or may not be associated with hemorrhoids. Symptoms of rectal prolapse can include pain, bleeding, or problems with defecation. Many patients experience both fecal incontinence and constipation. Careful examination is needed to determine if the rectal prolapse can be reduced. In cases where reduction is not possible, tissue incarceration and necrosis may develop. Patients with rectal prolapse should be referred to a colorectal surgeon or gastroenterologist for additional evaluation and treatment.
Several different systems have been designed to grade the degree of POP based on anatomic changes. The Baden-Walker system is commonly used in clinical practice, and classifies the degree of prolapse based on whether it extends beyond the midpoint of the vagina or beyond the vaginal introitus, when it is more likely to become symptomatic. The POP-Q system is more commonly used in research settings. It includes multiple anatomic measurements in relation to the vaginal introitus. In most systems, the hymenal ring is used to define the vaginal introitus. A clear understanding and documentation of the extent of prolapse is useful for surgical planning and for following progress over time.
Treatment of Pelvic Organ Prolapse
Most treatments are aimed at reducing the prolapse back into the vaginal canal and correcting vaginal anatomy (see Table 42-5). Ulcerations of the vaginal mucosa may respond to topical estrogen therapy. Barrier compounds may also be helpful to reduce tissue irritation.
Treatment of POP may be surgical or nonsurgical, and depends to some degree on the amount of bother experienced by the patient. It also depends on overall health status, and goals of therapy. The main conditions necessitating definitive treatment or specialist referral include nonhealing ulcerations, bleeding, elevated postvoid residual urine volume causing recurrent infections, and hydronephrosis. If none of these are present and the patient is not particularly bothered by her symptoms, then reassurance and observation are appropriate. Application of estrogen cream once or twice a week is advisable for preventive care and can help reduce tissue irritation and ulceration. On other days, use of a topical barrier cream such as solid vegetable oil may be helpful. Some patients may find comfort in using supportive underwear.
Pessaries are the main nonsurgical therapy used in the management of POP. These intravaginal devices come in a wide range of shapes and sizes, and are designed to reduce the prolapse. When correctly fit, most women cannot feel the pessary when it is in place. Selection of specific pessaries is based on patient anatomy and the experience and preference of the clinician. A pessary that is too large may be painful and increases the risk for tissue erosion. A pessary that is too small will tend to fall out with ambulation or other activity. Topical estrogen cream is useful to reduce the risk of tissue erosion and irritation. The pessary should be periodically removed and cleaned. If a patient is unable to do this herself, she should be seen by a clinician at least every 1 to 3 months for pessary cleaning and inspection of the vaginal tissues. Neglected pessaries can cause odor and increase the risk for infection or erosion. Case reports have shown that neglected pessaries can erode into the peritoneum, rectum, or bladder. Careful follow-up for pessary care is particularly important in older women with any degree of cognitive impairment to prevent forgetting that the pessary is in place.
Pessaries may also be used for the treatment of urinary incontinence. Special designs include a “button” that is placed under the urethra to increase outlet resistance and help reduce stress incontinence with increased abdominal pressure. Rarely women may need to remove the pessary in order to void to completion. Incontinence pessaries may be useful to identify women who might benefit from surgical correction of stress incontinence. A variety of urethral plugs and patches have also been designed for treatment of female stress urinary incontinence, although patients often find them difficult to use and compliance is generally low.
Surgical management of POP includes either reconstructive or obliterative procedures. Reconstructive options aim to reduce the prolapse and reestablish normal vaginal anatomy. Examples include anterior and posterior colporrhaphy and enterocele repair. Prolapse of the vaginal apex may require more advanced repair techniques. These include either open or robotic and laparoscopic uterosacral or sacrospinous ligament fixation, in which the apex of the vagina is sutured to a fixed point in the pelvis. In some cases, mesh or other supporting material is needed to perform this type of repair. Potential complications include mesh erosion through the vaginal wall or other surrounding structures. Colpocleisis is an obliterative procedure in which the prolapse is reduced and the vagina is essentially closed to prevent recurrence. It is technically easier and may offer an option for older women with substantial comorbidity who may not be good candidates for more involved reconstructive procedures. However, patients need to be carefully counseled that penetrative sexual activity will not be possible after colpocleisis. Studies have shown that in carefully selected patients, satisfaction rates are high with low rates of regret regarding the procedure. Rectal prolapse is typically treated surgically with either reduction or fixation, or excision of the prolapsed portion of the rectum. Treatments to prevent chronic constipation are indicated after all types of POP repair to avoid significant straining with bowel movements and prevent prolapse recurrence.
Although gynecologic issues comprise a small part of geriatric care, large impacts can be made on function and quality of life. A thorough personal and family history will guide cancer prevention and detection. An initial pelvic examination will provide the basis for understanding symptoms and anticipating problems, potentially for years to come. Querying problems will encourage the patient to voice symptoms when they arise. Persistence in addressing chronic incontinence and pelvic floor issues will prevent hopelessness and isolation. Ensuring adequate cervical cancer screening, early recognition of endometrial and vulvar cancer, and early investigation of abdominopelvic complaints to rule out ovarian cancer will reduce disease burden.
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