CHAPTER 51—GYNECOLOGIC DISEASES AND DISORDERS
HISTORY AND PHYSICAL EXAMINATION
TREATMENT OF MENOPAUSAL SYMPTOMS
TREATMENT OF UROGENITAL SYMPTOMS
VULVOVAGINAL INFECTION AND INFLAMMATION
DISORDERS OF PELVIC FLOOR SUPPORT
POSTMENOPAUSAL VAGINAL BLEEDING
Most older women do not seek regular gynecologic care. This may be in part because they are reticent about discussing personal gynecologic problems. Important and treatable disorders consequently go undiagnosed until they become severely disabling. For example, although urinary incontinence affects 16 million adults in the United States, the average time between onset and reporting to a physician is 8.5 years; gynecologic problems such as genital prolapse and atrophic vaginitis often exacerbate urinary incontinence. Full gynecologic examination should be a routine part of a complete history and physical examination for all older women who are amenable to screening.
The latest American College of Obstetrics and Gynecology recommendations for primary care of women aged 65 and older include inquiring about not only routine gynecologic issues but also about involuntary loss of urine or feces, sexual behavior patterns and potential exposure to sexually transmitted diseases, and use of alternative medical treatments.
Nongynecologic medical problems that can have significant gynecologic effects should be noted in the history. For example, breast cancer therapy typically leads to severe urogenital atrophy, obesity can result in hyperestrogenic states due to peripheral conversion of androgens to estrogen, and osteoporotic lordosis causes increased intra-abdominal pressure and resultant predisposition to genital prolapse. Previous obstetrical events may cause pelvic floor neuromuscular damage and eventual development of urinary incontinence and genital prolapse.
If a woman is on hormone replacement, the regimen should be reviewed annually to assure adherence, need for continued therapy, and absence of abnormal side effects. If the uterus is present, estrogen must be combined with a progestin in order to prevent the development of endometrial hyperplasia (see the section on hormone replacement therapy in Endocrine and Metabolic Disorders). The history should also include inquiry about abdominal distention (sign of ovarian cancer) and abnormal vaginal discharge or bleeding (signs of endometrial, cervical, or vaginal cancer).
The pelvic examination also presents an opportunity to discuss sexual function with the patient. Although the lack of available, sexually capable men may limit an elderly woman’s sexual activities, many older women are interested in maintaining sexual relationships. Issues related to sexual activity such as atrophy-related dyspareunia, postcoital bleeding, and sexually transmitted diseases should be addressed. Many women require reassurance that enjoyable sexual activity is possible and normal at their age. Also, women who maintain regular sexual activity are less likely to have significant vaginal atrophy.
Most ambulatory elderly women can assume the lithotomy position. Because the vaginal introitus may be small and stenotic, smaller speculums may be needed. The dorsal position, in stirrups for a pelvic examination, requires flexion and external rotation of the hips. Patients with osteoarthritis who find the lithotomy position uncomfortable or impossible to assume will need to use an alternative position. The left lateral decubitus position is one alternative. The patient lies on her left side, with knees flexed. The upper hip (right) is flexed to a greater degree and the right leg is elevated, exposing the perineum. An adequate speculum and bimanual examination can usually be done in this position. To examine a bedbound patient, position an inverted bedpan under the sacrum to elevate the pelvis. Water-based lubricants facilitate the examination and can be used if a Pap smear will be performed.
In performing the pelvic examination of an older woman, the examiner should:
The presence of significant vaginal mucosal atrophic changes may lead to inadequate or abnormal Pap smear interpretation. In this situation, the Pap smear should be repeated after 2 to 3 months of local estrogen therapy. Bimanual examinations and perineal inspection performed annually may detect vulvar, vaginal, or ovarian pathology. A rectal examination could also be performed at the same time in order to identify masses, detect occult bleeding, and evaluate the anal sphincter.
Ovaries become smaller with aging, and any palpable adnexal tissue should prompt consideration of malignancy. Although uterine fibroids are common, any increase in uterus size should be investigated. An ovarian or uterine mass could be evaluated by abdominal or pelvic ultrasound (using a vaginal probe) to determine location and character. Sonography, however, cannot definitively establish the nature (benign or malignant) of the mass, so further evaluation with laparoscopy ultimately depends on clinical judgment.
Estrogen is labeled by the U.S. Food and Drug Administration (FDA) for the treatment of menopausal symptoms and urogenital dryness and for the prevention of osteoporosis, but estrogen replacement therapy (ERT) has historically been used by clinicians for other reasons as well. The common short- and long-term uses, common prescribing practices, and risks of ERT are reviewed herein.
Menopause on average occurs at age 51 in the United States. With a life expectancy of 78 years, the average woman is postmenopausal one third of her life. Despite some controversy about the risks and benefits of ERT, many women and their physicians choose to treat or prevent the sequelae of estrogen deficiency in menopause, although the popularity of this therapy is waning in response to findings of the Women’s Health Initiative (WHI) trial.
Vasomotor symptoms or hot flushes are the most common symptom of the climacteric, occurring in up to 80% of perimenopausal women. Symptoms persist beyond 5 years in 25% of women and are lifelong in a small minority. Although the cause of the vasomotor response remains unknown, vasomotor symptoms are usually relieved within the first cycle of estrogen treatment. Low-dose therapy can be initiated and estrogen doses titrated until symptoms improve. When estrogen is contraindicated or not acceptable, selective serotonin-reuptake inhibitors or progestins are considered the second most effective therapies. ClonidineOL, methyldopaOL, or herbal remedies such as yams and black cohosh have also been tried with little evidence to support their use.
See also the section on hormone replacement therapy in Endocrine and Metabolic Disorders and the section on ERT and osteoporosis prevention in Osteoporosis and Osteomalacia.
Estrogen deficiency causes atrophy of both the vaginal and urethral mucosa. Both have a high density of estrogen receptors. Although randomized trials are few and have yielded variable results, a Cochrane Database Review suggests that estrogen may improve urge incontinence more than placebo.
See also Disorders of Sexual Function and Urinary Incontinence.
The lower genital tract is exquisitely sensitive to estrogen. Urogenital atrophy occurs in all postmenopausal women. Proliferation and maturation of the vaginal epithelium depends on adequate estrogen stimulation. With reduction of estrogen production, genital blood flow decreases, leading to further decline in delivery of estrogen to those tissues. This reduction in microvascularity leads to vaginal dryness, mucosal pallor, decreased rugation, mucosal thinning, inflammation with discharge, and, ultimately, decreased vaginal caliber and depth. With progressive atrophy, the vaginal Pap smear–maturation index shows atrophic changes with a decrease in mucosal superficial cells and an increase in intermediate and basal cells. Many women experience dyspareunia, burning, and even vaginal bleeding in some cases (Figure 51.1).
These changes are readily reversed with the administration of local estrogen. The intravaginal use of estrogen cream, one half an applicator (1 to 2 g) as infrequently as two nights per week, allows topical estrogen therapy with minimal (if any) absorption, endometrial proliferation, or other systemic effects. The available prescription estrogen creams appear to be therapeutically equivalent. The estrogen ring may be used for 3 months per ring, and vaginal tablets are available for use twice a week. Estrogen cream is also an excellent lubricant for use during intercourse or for pessary insertion. (See also Disorders of Sexual Function.)
Postmenopausal women are susceptible to a broad range of vulvovaginal infections. Candidal infection, common in diabetic and obese patients who are plagued with moisture and irritation, can be treated with oral, intravaginal, and topical antifungal agents. Patients should be questioned about their ability to insert a vaginal applicator before beginning therapy. Topical corticosteroids can be used to hasten relief of symptoms. Combination therapy may be necessary, as older women commonly present with more chronic, untreated candidal infections that spread from the vulva to the inguinal areas. Other vaginal infections common in reproductive age women such as trichomonas and Gardnerella vaginosis are less common in elderly women, likely because of the higher vaginal pH. A wet preparation revealing sheets of inflammatory cells without bacterial forms may represent advanced atrophy rather than an infectious cause. Local estrogen cream in the case of a symptomatic woman with atrophic vaginitis is effective.
With aging, the skin of the vulva loses elasticity, and the underlying fat and connective tissues undergo degeneration, with loss of collagen and thinning of the epithelial layer. Consequently, postmenopausal women not on estrogen are predisposed to a variety of dermatologic disorders and symptoms. The assessment of vulvar complaints must include direct examination. Any pigmented lesion or lesions that do not respond to topical corticosteroid or estrogen treatment must be promptly biopsied.
Vulvar skin irritation occurs from a variety of agents and causes burning, itching, and edema. Hygienic products used for urinary or fecal incontinence may lead to chemical dermatitis, as does urine itself. Treatment of incontinence is important to solving this problem. Vulvar burning or pain is rarely due to estrogen deficiency, and this complaint should be investigated rather than treated with ever-increasing doses of estrogen. Vulvar excoriation can result from scratching of an inflamed vulva. Local corticosteroids such as hydrocortisone 1% ointment applied daily, sitz baths, or use of a bidet can help alleviate vulvar irritation. Any chronically irritated area should be biopsied to exclude a malignancy.
Vulvar dystrophy is a somewhat outdated term used to describe both benign and malignant vulvar squamous changes. The preferred terminology set out by the International Society for the Study of Vulvovaginal Disease outlines three classes of nonneoplastic vulvar lesions. These are lichen sclerosus, squamous cell hyperplasia, and other dermatoses. A separate classification is used for biopsy-proven dysplastic lesions. These vulvar intraepithelial neoplasias (VIN) are graded on the basis of the level of atypia (dysplasia).
Lichen sclerosus causes over one third of all vulvar dystrophies and may extend beyond the vulva to the perirectal areas. It is rarely precancerous. There is epithelial thinning with edema and fibrosis of the dermis. It can progress to shrinkage and adherence of the labia minora with reduction in introital caliber. Lesions are typically shiny, white or pink, and parchment-like. Lesions may be asymptomatic or may cause itching, vaginal soreness, and dyspareunia. Diagnosis is confirmed on biopsy of the involved vulvar areas. Recommended treatment involves daily application of a rather potent topical corticosteroid, clobetasol propionate 0.05%. Treatment should be continued for at least 3 months. Testosterone had been the mainstay of therapy but has been shown to be significantly less effective than clobetasol. Further measures include wearing cotton underwear and avoiding irritant soaps. Topical emollient agents including lanolin can be helpful, but petroleum jelly should be avoided.
Squamous hyperplasia appears as thickened, hyperplastic, elevated white keratinized lesions that can be difficult to distinguish clinically from VIN or condylomata. However, it is benign. Biopsy should precede treatment. Topical mid-potency corticosteroids such as triamcinolone 0.1% twice daily for a few weeks (or longer with thick lesions) resolves the lesions; intermittent therapy may be necessary.
Other vulvar lesions include lichen simplex chronicus, which presents with vulvar pruritus, and lichen planus, which presents as erosive, ulcerative lesions that can result in significant vulvar scarring. Mid-potency corticosteroids applied topically or intravaginally are recommended. In lichen planus involving the vagina, local estrogen cream should also be used.
All suspicious, unusual, or symptomatic vulvar lesions should be biopsied. VIN lesions are not usually precancerous. VIN is most often seen in postmenopausal women, but the incidence of VIN does not increase with age. Over half of cases are asymptomatic. When symptoms are present, the most common is pruritus. The clinical appearance is the same as squamous hyperplasia or may be simply pigmentation. Lesions are often multifocal.
Invasive cancer of the vulva is an age-related malignancy; half of all cases occur after age 70. The vast majority are squamous cell carcinomas. Malignant melanoma, sarcoma, basal cell, carcinoma, and adenocarcinoma account for under 20% of cases. Treatment involves surgery (radical vulvectomy), occasionally accompanied by radiation.
Child bearing and activities that increase intra-abdominal pressure cause progressive weakening of the connective tissue and muscular supports of the genital organs and can lead to genital prolapse. Conditions such as constipation, chronic coughing, and heavy lifting commonly increase intra-abdominal pressure. Common symptoms of prolapse include pelvic pressure, lower back pain, urinary or fecal incontinence, difficulty with rectal emptying, or a palpable mass. Traditional classification of vaginal prolapse differentiated protrusion of the posterior vaginal wall (enterocele or rectocele), descent of the anterior vaginal wall (cystocele), and prolapse of the vaginal apex. These conditions are demonstrated by having the patient bear down or cough while in the dorsal lithotomy position, but the full extent of prolapse is better appreciated with a standing Valsalva’s maneuver. Vaginal prolapse represents a pelvic organ hernia through the vaginal hiatus.
The 1995 American College of Obstetrics and Gynecology classification of pelvic organ prolapse is outlined in Table 51.1. The International Continence Society and the American Urogynecologic Association adopted a new, rather complex prolapse classification system that is based on measurement of the distance between vaginal anatomic sites and the hymeneal ring. The purpose of this classification, which is used by specialty societies, is to more objectively and reproducibly describe a patient’s degree of prolapse.
Mild prolapse (1st or 2nd degree; see Table 51.1) can be retarded with adequate estrogenization and Kegel’s exercises to strengthen the pelvic floor musculature (see the Appendix, for exercise instructions for the patient). Genital prolapse does not always lead to bladder dysfunction and should not be assumed to be the cause of incontinence (see Urinary Incontinence). Correcting the prolapse will in some cases cause or exacerbate incontinence. On the other hand, large cystoceles or rectoceles may produce urinary retention, and reduction of the cystocele may restore normal bladder function.
Pessaries are commonly employed in an effort to delay or avoid surgery. Their use in older women may be indicated to provide comfort and restore bladder function when comorbid illness makes surgery undesirable. Such women may elect long-term pessary use under medical supervision. Available pessaries are made from rubber, plastic, or silicone. A variety of shapes and sizes are available: doughnuts, rings, cubes, inflatable balls, and foldable models. Pessary care requirements often influence the selection of a device and the amount of follow-up required.
The choice of pessary is influenced by the degree of prolapse, presence of incontinence, type of accompanying tissue relaxation, and ease of care. Patients with prolapse and no incontinence require only space-occupying types. Those with stress incontinence benefit from a foldable type, which restores bladder neck support. Ring pessaries are easier to insert and remove and may be preferred by older women.
Pessary selection often proceeds by trial and error; the optimal pessary fits snugly but comfortably and allows voiding and defecating without difficulty. After pessary selection and insertion, clinical follow-up within a few days is essential to ascertain satisfactory usage. After initial fitting and recheck, pessaries should be removed and cleaned, and the vaginal walls inspected. Pessary care requirements often influence the selection of a device and the amount of follow-up required for individual patients. If an older woman’s mobility or manual dexterity permit, she should be advised to remove the pessary twice a week, wash it with soap and water, and reinsert it with a water-soluble lubricant; she should use 1 g vaginal estrogen cream twice a week as well. Patients who cannot provide this level of self-care should be assisted at periodic office visits or by a visiting nurse. All patients with pessaries should be instructed to report any unusual discharge, bleeding, or discomfort, and any changes in bladder or bowel function, and all should have a pelvic examination once or twice a year. If discomfort is present or the device becomes uncomfortable, a different size or type should be tried. Pessaries do not work as well with marked vaginal outlet relaxation. If a pessary is left in place for long periods without monitoring, fibrous tissue may form around the pessary, and removal under anesthesia may be necessary.
Surgical treatment of vaginal prolapse can be classified as either reconstructive or obliterative. Reconstructive procedures are designed to restore normal anatomy, whereas obliterative procedures result in closure of the vaginal canal. Vaginal reconstructive procedures include sacrospinous fixation (for apical prolapse), anterior repairs (for a cystocele), and posterior repairs (for a rectocele). These can safely be done under regional anesthesia, which minimizes anesthetic risks. Abdominal reconstructive procedures include sacrocolpopexy (for apical prolapse) and paravaginal repairs (for a cystocele). They typically require general anesthesia. Urinary incontinence procedures can be done either vaginally or abdominally at the time of the prolapse surgery. (See also Urinary Incontinence.)
Obliterative procedures are restricted to elderly women who are not, and will not be, sexually active. In a LeFort colpocleisis, the anterior and posterior vaginal walls are sutured together, obliterating the vaginal canal. The simplicity and safety are very attractive for the oldest-old women, as the procedure can be done under local anesthesia in the outpatient setting. Anti-incontinence procedures can be done at the same time, as well. Limitation of physical activities and intra-abdominal pressure increase for 6 to 12 weeks postoperatively, the performance of pelvic floor exercises, and use of vaginal estrogen cream are key in optimizing the success rate of surgical therapy. The impact on quality of life of prolapse surgery for the patient can be quite remarkable, as a large, exteriorized prolapse can markedly limit a woman’s ability to perform physical and social activities.
Age, in itself, is not a contraindication to surgery for genital prolapse. When a proven protocol for perioperative care, including preoperative medical clearance, regional anesthesia, infection prophylaxis, and deep-vein thrombosis prophylaxis, is followed, vaginal surgery offers a safe alternative to pessary use for elderly women with symptomatic genital prolapse. (See also Perioperative Care.)
Postmenopausal bleeding (defined as bleeding after 1 year of amenorrhea) occurs in a significant number of older women. The challenge is not only to exclude gynecologic malignancies but also to alleviate the symptoms and eliminate the cause of benign conditions. Causes of bleeding can be grouped according to anatomic areas and endocrine dysfunction (Table 51.2). Not all complaints of postmenopausal bleeding are related to the reproductive organs but may be confused by the patients as originating from these areas. Proper evaluation involves complete physical examination and directed diagnostic studies. Endometrial hyperplasia and cancer can be evaluated with endometrial biopsy or by measuring the endometrial thickness on vaginal probe ultrasound. Though neither ultrasound nor biopsy is 100% specific, an endometrial thickness of less than 5 mm on ultrasound essentially excludes hyperplasia and malignancy. Dilation and curettage is reserved for cases where tissue cannot otherwise be adequately sampled or when bleeding persists. The use of direct visualization (hysteroscopy) during the procedure is the most accurate method for tissue sampling. New techniques for destruction of the endometrial lining (ablation) by heat, cold, or excision may be helpful in women whose bleeding is proven to be due to nonmalignant conditions.
Exogenous hormone replacement is a common cause of postmenopausal bleeding. Women on continuous combined estrogen-progesterone replacement who continue to have bleeding after 1 year must be evaluated. Some specialists recommend biopsy if bleeding persists beyond 6 months. Women on cyclic hormone therapy who bleed at an unexpected time during the cycle should also be evaluated. (See also the section on hormone replacement therapy in Endocrine and Metabolic Disorders.)
See the section on estrogen replacement therapy in Endocrine and Metabolic Disorders.
■ Adams E, Thomson A, Maher C, et al. Mechanical devices for pelvic organ prolapse in women. Cochrane Database Syst Rev. 2004(2):CD004010.
This review is the most up-to-date information regarding the state of evidence involved in treating pelvic organ prolapse with devices. The authors found that the evidence is sparse and the data are insufficient to recommend particular devices for particular indications.
■ American College of Obstetricians and Gynecologists. Vulvar Non-neoplastic Epithelial Disorders. ACOG Educational Bulletin No. 241. Washington, DC: American College of Obstetricians and Gynecologists; 1997.
Vulvar disorders typically found in elderly women are classified and described, and treatment options are discussed. No illustrations are provided. Because of the variable physical appearance of vulvar changes, a biopsy is recommended for any suspicious or changing lesion. Strong corticosteroid ointments are commonly required for treatment of lichen sclerosus.
■ Bash KL. Review of vaginal pessaries. Obstet Gynecol Surv. 2000;55(7):455–460.
This is a practical, useful review for practitioners. All of the major pessary types and their usage are described, with helpful illustrations.
■ Neimark M, Davila GW, Kopka SL. Le Fort colpocleisis: a feasible treatment option for pelvic organ prolapse in the elderly woman. J Pelv Surg. 2003;9(2):83–89.
As the population ages, it is increasingly important to evaluate treatment options for disorders prevalent among elderly women, such as pelvic organ prolapse. Bowel and bladder function and overall quality of life were investigated in elderly women who received a Le Fort colpocleisis. The results showed that Le Fort colpocleisis is a viable treatment option for severe vaginal prolapse in the elderly patient. Low postoperative quality-of-life impact scores, despite irritative bladder symptoms and constipation, demonstrate the beneficial outcome of colpocleisis in elderly women with advanced genital prolapse who are not sexually active.
■ Tabor A, Watt HC, Wald NJ. Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding. Obstet Gynecol. 2002;99:663–670.
A literature review was performed to assess the value of endometrial thickness measurement as a test for endometrial cancer in postmenopausal women with vaginal bleeding. The authors conclude that with a 4% false-negative rate and a 50% false-positive rate, endometrial thickness measurement in postmenopausal women with vaginal bleeding should not replace invasive diagnostic testing (ie, dilatation and curettage).
G. Willy Davila, MD