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

Osteoporosis
estrogen deficiency related bone loss occurs at an accelerated rate of 2-3% of bone mass for up to ten years following menopause. Complications resulting from this loss include vertebral fracture, fractures of the femoral head, chronic back pain, and loss of height with pulmonary compromise. The use of HRT, together with weight bearing exercise and calcium supplementation (1500 mg./day), can delay and prevent the morbidity and mortality associated with these complications.
Coronary Artery Disease
estrogen has a documented protective effect against coronary artery disease through the alteration of the cardiac lipid profile with an increase in the HDL and a decrease in the LDL components. While the progestin may negate some of the beneficial effects, its use is necessary to prevent endometrial hyperplasia.
Genital Atrophy
estrogen deficiency can lead to an increased incidence of urinary incontinence, urinary tract infections, dysuria, dyspareunia, and genital prolapse. The use of HRT can reverse or ameliorate many of the symptoms.
Alzheimer's Disease and Mental Acuity
preliminary studies indicate a protective effect of HRT against Alzheimer's Disease with a preventative fraction as high as 40%. Of those women who did develop Alzheimer's disease, a delayed onset and lessening of the severity of symptoms were noted. The use of HRT in women with Alzheimer's suggested a decrease in severity of symptoms. Among healthy women, HRT has been shown to objectively increase memory, short term information retention, and cognitive reasoning. Subjectively, women on HRT report mood elevation and a reduction in "sad thoughts".
Osteoarthritis
recent studies have shown a decrease in the incidence and severity of osteoarthritic changes in users of HRT. This effect is believed to be due to the increased collagen at the joints caused by estrogen.
Tooth Loss
non-carious tooth loss in the elderly is most commonly caused by bone loss in the jaw. HRT has been shown to decrease this rate of bone loss and increase tooth retention.

Potential Risks of HRT

Endometrial Hyperplasia
given long enough, estrogen alone will induce an endometrial hyperplasia or cancer. The addition of aprogestin, given properly, will not only counteract this risk but reduce the incidence below that of a woman taking no HRT. A minimum of 13 days of a progestin or its biologic equivalent (i.e., medroxyprogesterone acetate 10 mg. for 10 days) is necessary to reduce this risk.
Breast Cancer
perhaps the greatest fear of women using HRT and the greatest barrier to its use, the relationship between HRT and breast cancer has become somewhat clearer. It appears that the relationship is both time and dose dependent. At doses of 0.625 mgs. conjugated estrogen equivalent, it takes approximately 15 to 20 years before an increase of 0.4% is seen. With higher doses, the time frame remains the same but the excessive risk increases. Interestingly, women who do develop breast cancer while using HRT appear to have less metastases and better survival rates compared to non-users diagnosed at equivalent states.
Thromboembolism
there is no evidence to suggest an increased rate of thromboembolism with the doses of estrogen used for HRT in normal women. Women with a prior history of thromboembolic disease may have intrinsic alterations in blood vessel lining which may place the patient at increased risk.
Hypertension
there is no equivalent elevation of blood pressure as seen with oral contraceptives. Estrogen therapy has been shown to mildly decrease diastolic blood pressure with little or no effect on systolic pressure. Patients who have known hypertension may be exacerbated by HRT. This elevation is usually reversible and not associated with an increased risk of stroke.
Glucose tolerance
HRT is not associated with impaired glucose tolerance.

SCHEDULES OF HRT:

There are three routes of estrogen administration available:

Typical HRT schedules:

Conjugated estrogen 0.625mg. * days 1-25 each month and medroxyprogesterone acetate 5 to 10 mg. day 13 to 25 each month. No hormones are given during the remainder of the month. Most patients demonstrate withdrawal bleeding during the hormone free interval.
Continuous conjugated estrogen 0.625 mg. * every day and medroxyprogesterone acetate 5 to 10 mg. day 1 to 13 each month. Expect withdrawal bleeding following progesterone withdrawal.
Continuous conjugated estrogen 0.625 mg. * every day and medroxyprogesterone acetate 2.5 mg. every day. Many patients may have irregular bleeding but 95% will become ammenorrheic within one year.

* 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.