Geriatric Gynecology
Lane Jay Mercer, M.D.
Older women have a number of gynecologic problems which generally respond well to simple therapies.
Vulva
Atrophic changes are a natural sequelae of estrogen deficiency
characterized by loss of normal architecture, thinning of the
skin, and "cracking" of the dermal layers. Treatment
is the restoration of estrogen which can be accomplished systemically
or topically. In severe cases of atrophy, the application of topical
estrogen creams may cause burning. This can be overcome by mixing
a mild steroid cream (e.g. 0.5% cortisone cream) with the estrogen
for a short period of time. Prolonged use of the steroid cream
can lead to steroid atrophy and should be avoided.
Chronic vulvar puritis or irritation which does not respond to
estrogen therapy must be fully evaluated. Chronic fungal vulvitis
is recognized by erythema and a "glossy" texture of
the skin. Predisposing conditions include diabetes, steroid use,
urinary incontinence, obesity, and hypothyroidism. The diagnosis
is established by microscopic examination of vulvar scrapings
suspended in potassium hydroxide for pseudohyphae. Treatment is
topical or systemic antifungal agents and correction of the underlying
medical condition. Lichen sclerosis is a vulvar dystrophy characterized
by chronic puritus, loss of labial architecture, and chronic thinning
of the skin. Its etiology is unknown but believed to be auto immune.
Treatment has traditionally been the use of anabolic steroids,
testosterone propionate 2% in petrolatum, applied sparingly twice
a day and rapidly tapered once symptomatic relief is accomplished.
Chronic intermittent application must be done to prevent recurrence.
More recently, the use of potent steroid ointments (i.e. Temovate)
have proven to be successful with fewer side effects than testosterone.
However, the doses must be tapered rapidly to prevent steroid
atrophy.
Raised or thickened vulvar skin must cause concern for vulvar
intraepithelial neoplasia, premalignant lesions. These lesions
should be biopsied to establish the diagnosis. Diffuse vulvar
thickening may represent hypertrophic dystrophy in which discoloration
and an "alligator skin" appearance is seen. This condition
has some malignant potential. Therefore, any suspicious areas
should be biopsied. Treatment consists of topical steroid ointments
applied intensively and then tapered rapidly. Chronic maintenance
therapy must be done to prevent recurrence. Surveillance for malignancy
should be done on a minimum of a semi-annual basis, looking for
new raised or ulcerated areas.
All persistent ulcerated lesions must be considered as cancer
until proven otherwise by biopsy. Pigmented lesions should be
treated similarly to skin lesions found on any other part of the
body. The vulva is a common site for melanoma. All raised lesions
which bleed or grow rapidly should likewise be biopsied. As condylomata
accuminata are rare in the postmenopausal woman, verrucous lesions
should be excised to rule out verrucous carcinoma.
Vagina
Postmenopausal changes of the vagina include the loss of the thick
keratinized mucosa, decrease in the amount of glycogen produced
by the vaginal epithelium, and a decrease of fascial thickness
underlying the mucosa. These changes are seen clinically as a
thinning of the vaginal walls, loss of rugae, and atrophy of vaginal
size.
The most common cause for vaginal discharge in the estrogen deficient
woman is atrophic vaginitis characterized by a watery white
discharge, vaginal pH elevated to 4.0 or greater, and microscopic
examination showing multiple white blood cells, few bacteria,
and many exfoliative cells. Treatment is the application of estrogen.
Women in whom estrogen is contraindicated may use the over-the-counter
vaginal lubricant, Replens®, which acidifies and coats the
vagina to minimize symptoms. All women with symptomatic vaginal
discharge should undergo a complete examination including vaginal
pH and microscopic examination with saline and potassium hydroxide
to rule out the common causes of vaginitis which may occur, including
trichomoniasis, bacterial vaginosis, and fungal vaginitis.
Cystocele and rectocele are defects of the anterior
and posterior vaginal walls, respectively. Although most probably
caused by the birthing process and chronic downward forces, they
are undoubtedly exacerbated by estrogen deficiency. Symptoms include
chronic pelvic pressure, recurrent urinary tract infections, a
mass protruding from the vagina, and difficulty defecating. While
mild relaxation of the vaginal walls can be tolerated, marked
prolapse can lead to ulceration of the vagina, fistulization,
acute urinary retention, urosepsis, and urinary incontinence.
Surgical therapies are well established and successful. Patients
unable to tolerate surgery can be fitted with a pessary, an intravaginal
device which lends support to the defect. Pessary care requires
cleaning, monitoring of the vagina for ulceration, and refitting
on a regular periodic basis and should be left to one familiar
with these devices.
Uterus
Postmenopausal changes of the uterus include a decrease in the
size of the fundus relative to the cervix, a decrease in myometrial
thickness, and a thinning of the endometrium. Hormone replacement
therapy will maintain some of the endometrial thickness but the
size of the uterine fundus will decrease. Any increase in the
size of the uterus must be fully evaluated to rule out leiomyosarcoma
or endometrial carcinoma.
All postmenopausal bleeding needs to be fully evaluated regardless
of the amount or duration. It is estimated that 0.1% of all menopausal
women have an occult endometrial carcinoma. The most common cause
of postmenopausal bleeding is atrophic vaginitis, but this diagnosis
should be one of exclusion. Evaluation of the endometrium includes
endometrial sampling and ultrasonic assessment of the endometrial
stripe. Endometrial sampling can most often be accomplished in
the office setting with a high degree of accuracy. Rarely is dilatation
and curettage necessary as the primary evaluation technique. Ultrasound
can be utilized to measure the endometrium with known thickness
highly predictive of pathology. This technique can also be used
to diagnose polyps and submucosal lesions.
Ovaries
The postmenopausal ovary decreases in size even during use of
hormone replacement and should not be palpable by routine pelvic
examination. Any enlargement of the ovary should be considered
a malignancy until proven otherwise. Only a small percentage of
ovarian carcinoma are familial (8-10%) with most arising without
antecedent family history. As symptoms of ovarian cancer
are subtle and non-specific, most are diagnosed in the late stages
when treatment is less successful. Symptoms include unexplained
weight loss, increased abdominal girth, and obstipation. Initial
evaluation of an ovarian mass should include an ultrasound characterizing
the size, composition (solid, cystic, or mixed), the presence
of septations or papillations, and extra-ovarian changes such
as peritoneal excrescence. The cancer antigen blood test, CA-125,
can detect non-mucinous epithelial tumors but can be falsely elevated
be intrinsic liver disease, other causes of peritoneal irritation
(e.g., diverticulitis), or non-malignant causes of ascites.
Hormone Replacement
Therapy
The use of hormone replacement therapy (HRT), in spite of its
proven benefits, remains controversial to many practitioners.
Fear of malignancy, blood clot, and physical changes prevent many
women from receiving the benefits of these medications. Women
using HRT will live, on an average, 20% longer and with a better
quality of life than their non-using peers. HRT most often consists
of an estrogen for patients without a uterus and an estrogen and
progestin for women with a uterus.
Prior to the initiation
of HRT, one should:
Absolute contraindications
to HRT:
Relative contraindications
to HRT:
Benefits of HRT
Potential Risks of
HRT
SCHEDULES OF HRT:
There are three routes of estrogen administration available:
* or any equivalent estrogen
compound
Use of estrogen vaginal cream 1 to 2 gm. three times per week
may be used for urogenital symptoms. However, after two weeks
of use, vaginal creams give serum levels equivalent to oral estrogen
levels. Therefore, progestins must be given to women with an intact
uterus in order to prevent endometrial hyperplasia or cancer.