Vulvovaginitis

Vulvovaginitis is a common complaint in the postmenopausal female. The lack of estrogen and the normal aging process leads to increased irritation of the vaginal tissue, along with increased susceptibility for trauma and infection. The three most common causes of vulvovaginitis complaints are atrophy, candidiasis, and lichen sclerosis.

Atrophic changes of the vulvovaginal area are very common following menopause, when the decreased presence of estrogen leads to thinning of the vaginal tissue. Physical findings include atrophic vaginal tissue that may be pale, smooth, and shiny; erythematous and friable with petechiae; loss of natural ruggae; and introital stenosis.[5] Intravaginal lubricants and long-term use of moisturizers can be helpful in treating mild to moderate symptoms.[6–8] Topical estrogen creams are the most effective at treating severe postmenopausal atrophic vaginitis.[6–9] It should be noted that unopposed systemic estrogen has been shown to increase risk of endometrial cancer; however, the risk is lower in topical formulation and does not require concurrent treatment with progesterone.[6, 7]

Vulvovagnitis caused by Candida infection, candidiasis, presents similarly in patients of all ages, with complaints of pruritus, irritation, and discharge. Physical findings include inflammation, erythema, along with a discharge demonstrating buds and hyphae on microscopy. Treatment is similar for all age groups, including several different antifungals in topical or suppository formulations, or with a single dose of fluconazole in oral form.[3]

Lichen sclerosis may present with thin, white “cigarette paper” patches and can be treated with topical steroids.[1] Patients with this diagnosis should be examined annually, as lichen sclerosis has been associated with certain cancers. Biopsy is indicated in any of the following findings: asymmetry, border irregularity, color variation, sudden change, bleeding, nonhealing ulceration, persistence, and lack of firm diagnosis.[4]

Pruritus

The differential for pruritus without discharge is large and includes primary dermatologic conditions, as well as manifestations of systemic illnesses. (See Table 28.1 for a full differential diagnosis.) A complete history should be obtained, including use of topical creams, lotions, detergents, and bath products. Any ulcerations or lesions may warrant biopsy to rule out vulvar intraepithelial neoplasia (VIN) or squamous cell carcinoma.

Vaginal discharge

Any vaginal discharge should be evaluated by pelvic exam, vaginal pH, and wet prep, with screening and culture for STIs when indicated. The three most common causes of vaginal discharge are caused by bacterial vaginosis, trichomoniasis, and candidiasis. Bacterial vaginosis occurs when various anaerobes replace normal vaginal flora. Treatment for bacterial vaginosis is the same in elderly as in younger patients, with either oral metronidazole or clindamycin, or topical metronidazole.[10] Trichomonas may cause foul-smelling discharge and may be treated with single 2-g dose of metronidazole. Candidiasis presents with irritation, pruritus, and/or discharge and may be treated as previously discussed.[10] The differential diagnosis for chronic vaginal discharge includes desquamative inflammatory vaginitis, chronic endometritis with malodorous purulent discharge, vesicovaginal fistula or enterovaginal fistula following bowel inflammation and injury as in cases of diverticulitis.[1, 4]

Vulvodynia

Vulvodynia is pain or discomfort of the vulva. Typically women describe a burning, stinging, irritation, or rawness. Vulvodynia without evidence of infection, dermatologic conditions, or vagina atrophy can be treated with topical lidocaine and low-dose antidepressants. There is weak evidence that a low oxalate diet may reduce symptoms.[1]

Bleeding

All postmenopausal bleeding requires a workup to rule out endometrial cancers. Benign causes of vaginal bleeding include atrophic endometrium, cervicitis, cervical or endometrial polyps, hormone therapy (HT), endometriosis, leiomyomas, vaginal atrophy and friability.[11] The workup should include a full history, medications including HTs (i.e., tamoxifen), a complete exam to evaluate for causes of bleeding other than vaginal (i.e., hematuria or rectal bleeding); an ultrasound to evaluate endometrial lining, and an in-office endometrial biopsy if the endometrial lining is abnormal. Hysteroscopy with D&C may be indicated in refractory or inconclusive cases and would warrant referral to a gynecology specialist.[1]

Sexually transmitted infections

The elderly are at increased risk of contracting STIs. The number of elderly patients with HIV has been slowly increasing.[10] There has been an overall increased incidence across all age groups of chlamydia, gonorrhea, and syphilis since 2011.[10] The Centers for Disease Control and Prevention (CDC) reports 3.4/100,000 new cases of chlamydia in men over age 65, and 2.2/100,000 new cases in women over age 65. Gonorrhea cases have shown a 4% increase since 2011, accounting for 537/100,000 men over 65 years and 105/100,000 women over 65 years. The incidence of syphilis has increased by 11% since 2011, with 138/100,000 new cases in patients over 65 years.[10]

Age-related vaginal atrophy creates micro-tears in the vaginal mucosa allowing bacteria more access, while a waning immune response makes those tears more susceptible to infection. Clinicians should encourage open communication between sexual partners and educate the patient about safer sex techniques, including use of latex condoms and limiting the number of partners, to reduce the risk of infection and illness. Any presence of rash, blisters, or discharge should be evaluated right away.[2]

Advancing age, frailty, and cancer screening

Frailty should be considered in the risk and benefit profile when deciding whether to screen for cancer in the older adult. The utility of cancer screening may decrease with increasing age and frailty. Upper age limit for cancer screening varies from different organizations such as the American Cancer Society (ACS), the US Preventive Services Task Force (USPSTF), and the American College of Obstetricians and Gynecologists (ACOG), due to limited research data in the older geriatric population. Cancer screening is generally not recommended for women with less than five years’ life expectancy.[12]

Vulvar cancer

Cancers of the vulva usually present with persistent itching and a vulvar mass.[13] Vulvar cancer accounts for approximately 5% of gynecologic malignancies, and occurs most frequently in women 65–75 years old.[14] The most common cancer is vulvar squamous cell carcinoma. Melanoma accounts for 2%– 9% of vulvar cancers.[15] Warty appearing lesions such as verrucous carcinoma may also occur in postmenopausal women. Precancerous lesions include vulvar intraepithelial neoplasia, which is associated with human papillomavirus (HPV) infection. Suspicious lesions in the vulva should undergo biopsy to confirm diagnosis. Treatment for vulvar cancer is primarily surgical resection. Surgery also determines the extent of disease and the need for additional radiation or chemotherapy.[13]

Vaginal cancer

Vaginal cancers typically present with painless bleeding. Primary vaginal cancers account for only 3% of gynecologic malignancies.[14] Squamous cell carcinoma is the most common histologic type and occurs in older women. Melanoma may also rarely occur in older women. Vaginal cancers can be metastatic from other primary sources such as the cervix, rectum, and ovary.[16] Risk factors for primary vaginal cancers include persistent HPV infection, multiple sexual partners, early age at first intercourse, and prior anogenital malignancy.[17] Although a Papanicolaou (Pap) smear may occasionally detect abnormal cells from the vagina, the diagnosis of vaginal cancer usually occurs with direct visualization of the vagina and biopsy of the suspected lesion. Treatment for vaginal cancer is primarily surgical excision or radiation based on disease stage and patient factors.[18]

Cervical cancer

The presentation for cervical cancer is usually postcoital bleeding and vaginal discharge or spotting. Cervical cancer is the third most common gynecologic malignancy in the United States, although cervical cancer deaths in the United States have decreased overall due to increased cervical cancer screening.[14] HPV acquired mainly through sexual transmission has been found to be the oncogenic pathogen that causes cervical cancer. Risk factors that increase exposure to HPV include early sexual activity, multiple partners, and STIs. Immunosuppression and smoking are also associated with increased risk of cervical cancer. Twenty-five percent of new cases of cervical cancer are diagnosed in women over the age of 65.[19] Updated cervical cancer screening guidelines from ACOG and ACS recommend screening older women over the age of 30 every three years with cytology or, preferably, every five years with cytology and HPV DNA co-testing.[20, 21] Guidelines from ACOG, ACS, and the USPSTF recommend to stop screening for cervical cancer in women over the age of 65 who have had a history of adequate cervical cancer screening.[20–22] Adequate cervical cancer screening is defined by these current guidelines as having had three consecutive negative cytology results or two consecutive negative co-testing (cytology and HPV testing) results within the past 10 years, with the most recent test done within five years.[20–22] Women who have had a total hysterectomy with removal of the cervix for benign lesions such as uterine fibroids do not require further screening.[20–22] Most new cases of cervical cancer occur in women who have never had a Pap smear or have not had one for many years.[23] The ACS recommends screening for women who have not been previously screened or in whom screening information is not available. The ACS and ACOG also recommend continued screening for women with precancer lesions such as CIN2 or higher for at least 20 years after regression or treatment.[20, 21] The result of abnormal Pap screening or presence of high-risk HPV strains 16 and 18 as well as persistence of any high-risk HPV type for one year must be confirmed by colposcopy and biopsy of abnormal areas on the cervix. Treatment depends on the extent of the precancerous or cancerous lesion. Low-grade intraepithelial lesions may require only close monitoring or cryosurgery. Loop electrosurgical excision procedure (LEEP), laser, and cold knife conizations are used in women at high risk for cervical cancer with high-grade intraepithelial lesions. Radical hysterectomy and/or radiation therapy is the treatment for women with invasive cervical cancer.[24]

Endometrial cancer

Endometrial cancers commonly present with postmenopausal bleeding, and for this reason it is generally diagnosed in the early stages. Endometrial cancer is the most common gynecologic cancer in the United States. The lifetime incidence is 2.5% in the United States.[14] The majority of cases occur in postmenopausal women aged 50 and older. The most common type of uterine cancer is adenocarcinoma of the endometrium (lining of the uterus).[25] Endometrial cancer is estrogen responsive, so the greatest risk factor is exposure to excess estrogen therapy either exogenous or endogenous. The use of unopposed exogenous estrogen such as with hormone replacement therapy without progestin causes endometrial hyperplasia, which can lead to endometrial cancer. The use of tamoxifen, which is a selective estrogen receptor modulator, increases the risk of endometrial cancer in postmenopausal women.[26] Other risk factors associated with increased excessive endogenous estrogen include obesity, early menarche, late menopause, and nulliparity.[27] Women with hereditary nonpolyposis colorectal cancer (HNPCC) have a high risk – up to 40%–60% lifetime risk – of developing endometrial cancer.[28] These women develop endometrial cancer at an earlier age. Prolonged oral contraceptive use and cigarette smoking protect against endometrial cancer.[29, 30] Increased physical activity, coffee, and green tea consumption have also been associated with decreased risk of endometrial cancer.[31–33] Endometrial cancer, when diagnosed in the early stages, has an approximately 90% survival rate.[34] Endometrial biopsy, measurement of the endometrial stripe thickness on ultrasound, or hysteroscopy can be used to evaluate for endometrial cancer in women who present with postmenopausal bleeding.[35] Treatment of endometrial cancer usually includes surgery for total hysterectomy, bilateral salpingo-oopherectomy, and peritoneal washings. Then depending on the staging of endometrial cancer, radiation and chemotherapy is used in women with metastatic disease.[25]

Ovarian cancer

Ovarian cancer is often detected at advanced stages due to a lack of early symptoms. It is the second most common gynecologic cancer, but it has the highest death rate of all the gynecologic cancers with an overall five-year survival rate for white and black American women of 46% and 37%, respectively.[14] Many women with ovarian cancer in the early stages may be asymptomatic or have vague complaints of abdominal fullness, early satiety, nausea, constipation, gas, pelvic pressure, and low back pain. Clinicians need to have a high index of suspicion in these women to evaluate for ovarian cancer. Women with advanced disease may present with weight loss, intra-abdominal mass, or intestinal obstruction. Currently available screening tests have not proven to be beneficial for screening low-risk, asymptomatic women. ACOG recommends annual pelvic examination to evaluate for ovarian mass.[36] The USPSTF recommends against screening for ovarian cancer in asymptomatic women. However, women with a family history for breast and ovarian cancer should be considered for genetic counseling to evaluate their potential risks. Women with BRCA1 and 2 genetic mutations and Lynch syndrome (hereditary nonpolyposis colon cancer) are at an increased risk of ovarian cancer.[37] Advancing age, race, nulliparity, infertility, and history of endometrial or breast cancer have been associated with an increased risk of ovarian cancer. Multiparity, breastfeeding, and previous use of oral contraceptives have been linked to reduced risk of ovarian cancer.[38] The cancer antigen-125 (CA-125) is a tumor marker for epithelial ovarian cancer, which is the most common type of tumor in women older than 50. The CA-125 level is used for monitoring women with known ovarian cancer, but it is not sensitive or specific for use in screening in asymptomatic women.[39] Although an adnexal mass discovered in a postmenopausal woman is suspicious for ovarian cancer, benign ovarian cysts are not uncommon.[40] Women who have an adnexal mass palpated on pelvic examination should have diagnostic imaging performed initially with transvaginal ultrasonography. Ultrasound characteristics such as complex masses with cystic and solid components, septated cysts, thick cyst walls, and free fluid in the pelvis are concerning for malignancy.[41] Simple cysts up to 10 cm have lower likelihood of malignancy. The majority will resolve spontaneously and can usually be followed by serial transvaginal ultrasonography.[42] Gadolinium-enhanced magnetic resonance imaging is more specific compared to ultrasonography and may be used for further evaluation of concerning ovarian masses.[43] In postmenopausal women with a pelvic mass, a CA-125 may be helpful in predicting a higher likelihood of a malignant versus benign tumor.[36] Serum tumor markers should be used together with transvaginal ultrasonography to identify ovarian masses at high risk for malignancy.[44] Current treatment for ovarian cancer includes aggressive debulking surgery and chemotherapy.[45]