In the United States, women comprise 60% of the older population, so that geriatricians need a working knowledge of gynecologic care, including cancer screening, symptom evaluation, and assessment of incidental findings. After first presenting suggestions for a gynecological history and physical examination in an older woman, this chapter addresses findings and issues in the order they would be approached on a physical examination. Following this, evaluation and management of some common gynecological issues are presented. Management of incontinence with pessaries is included in this chapter, but other incontinence issues are dealt with in Chapter 59. Gynecological care encompasses management of benign breast disease, which is also included in this chapter. Hormone replacement therapy (HRT) is discussed primarily in Chapters 46 and 47, but discontinuation and topical therapies are addressed here.
A gynecologic history (Table 48-1) should include age of menarche and menopause, use of hormone replacement (indication, type, route, dose, timing of onset in regards to menopause, duration), current sexual activity, new sexual partners, past gynecological or urogynecologic procedures and their indications, number of pregnancies carried beyond 20 weeks, exposure to diethylstilbestrol (DES), Papanicolaou (pap) smear frequency and results in the past 10 years, mammographic screening in the past 5 years, breast cancer, gynecologic cancers, and history of pelvic irradiation. If urogynecological procedures were performed, note whether the symptoms were resolved, and whether they recurred. Important family history includes gynecological and other malignancies.
Table 48-1 Gynecological Periodic Examination |Favorite Table|Download (.pdf)
Table 48-1 Gynecological Periodic Examination
Mammography annually (or biennially) until reduced life expectancy
Cervical cytology annually if risk factors, triennially if no risk factors
(Upper age limit disputed, no limit per ACOG, age 70 per ACS)
Mammogram more useful than pap smear. (Shorter lead time for breast cancer.)
Hormones: menarche, menopause, past and current hormone use
Current hormone use
Breast complaints: pain, lump, nipple discharge
Staining of brassiere or clothing
Vulvovaginal irritation, bulge, bleeding, discharge
Apparent discomfort in perineal area
Urinary issues: incontinence, frequency, urgency, hesitancy, nocturia
Toileting practices, pad use
Defecation issues: Constipation, incontinence (gas, liquid, solid)
Defecation frequency, stool consistency
Sexual practices, contacts, satisfaction, abuse
Breast examination annually
Breast examination annually if tolerated
Pelvic examination every 1 to 3 yrs
External genitalia/perineum: architecture, integument
Urethra: meatus visibility, condition
Bladder: tenderness, fullness
Vagina: integument, discharge
Cervix: lesions, growths
Adnexa: palpability, mass
Annual inspection of external genitalia is potentially useful. Initial internal examination is worthwhile, but subsequent examinations may have lower benefit except for fecal impaction.
DES was first synthesized in 1938, and until as late as 1971 was employed to reduce pregnancy complications. Women ranging in age from 50 to over 100 years ...