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.

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 could have received DES during pregnancy. These women have an increased risk of breast cancer, but not of other gynecological malignancies. DES exposure in utero increases the risk of adenocarcinoma of the cervix and vagina mainly in adolescence and the third decade. These women are just beginning to enter geriatric age. The older ones in this cohort (age 40 years and above) have shown an increased incidence of breast cancer compared to women not exposed in utero, so continued surveillance is warranted. Current recommendations are to follow age-appropriate screening guidelines.

Additional information that is sometimes relevant includes total parity (spontaneous or induced abortions, preterm deliveries, term deliveries), route of deliveries (vaginal or cesarean), obstetrical trauma, and past contraception used (especially hormonal). The older a cohort of women, the less the association of current urogynecologic disorders with obstetrical history. Therefore exact knowledge of parity, route of delivery, highest birth weight, or use of forceps have little bearing on understanding etiologies and planning nonsurgical management in advanced age.

The gynecological review of symptoms should include breast pain or lump, nipple discharge; pelvic pain; vaginal bulge, pressure, discomfort, discharge, or bleeding; vulvar irritation, lumps, or rashes; irritative voiding symptoms (frequency, urgency, dysuria), urinary and fecal incontinence or urgency; difficulty voiding or defecating; sexual activity; and sexual abuse.

Breast examination should be performed annually (see Table 48-1). Pelvic examination recommendations for older women vary. Specific utility or cost-effectiveness of the pelvic examination apart from cervical cancer screening in older women has not been studied. Oftentimes despite a negative review of systems, problems are remembered by the patient during the pelvic examination. It may be that the more frail or cognitively impaired the patient, the more important the examination because of a lack of reporting ability. The American College of Obstetricians and Gynecologists (ACOG) recommends an annual pelvic examination in asymptomatic patients. Some chronic conditions have a medical indication for annual reexamination, such as lichen sclerosus. Because of Medicare regulations excluding payment for preventive care, patients with lichen sclerosus, pelvic organ prolapse, and other chronic conditions should be educated that they need the pelvic examination annually because of their condition, not for a “routine pap smear.”

Breast examination includes axillary, supraclavicular, and infraclavicular lymph nodes. During the abdominal examination, the inguinal lymph nodes should be assessed. Performance of the pelvic examination in older women requires more patience, ingenuity, leg positioning, and speculum variety than in younger women. Use of additional assistants or a central foot rest may allow the patient to be examined in the dorsal lithotomy position. Both genital inspection and internal bimanual examination can also be performed in the lateral decubitus position, albeit with less certainty about the bimanual palpation of internal organs and assessment of pelvic organ prolapse. Examination in the standing position may be necessary to demonstrate the extent of prolapse. If the examination needs to be performed in a bed, the patient’s hips can be elevated on an upside-down bed pan covered with a folded towel or on a stack of towels to allow speculum insertion.

Typical age-related changes of the external genitalia include decreased fat content of the mons pubis and labia majora and diminished pubic hair. Vulvar structures include a right and left labium majus, a right and left labium minus, and the clitoris. The labia minora meet anteriorly to form the clitoral hood at the distal end of the clitoris. Each of these structures should be noted upon examination. The clitoris may be prominent because of a predominance of androgen relative to estrogen, or it may be obscured by labial fusion. The urethra may not be easily visualized if it has receded into the vaginal canal from atrophy or is obscured by fused labia. Lifting the labia anteriorly without lateral stretching will usually allow meatus visualization without undue pain. “Perineum” refers to the entire vulva, perineal body, and anus, that is, the approximate boundary of the pelvic outlet, through which the urogenital ducts and rectum pass. However, it is also used to indicate the area between the anus and posterior part of the external genitalia, especially in lay publications and Medicare documents. These areas should be inspected and their neurological status examined. Sensation to light touch in the labia majora and perianal regions correspond to the lower lumbar (L4–L5) and sacral (S2–S4) dermatomes. Altered sensation, including asymmetry, may be associated with voiding, defecatory, or sexual dysfunction.

Speculum examination is facilitated by having an adequate variety of specula, including very narrow with normal length. Pediatric specula are appropriately narrow but usually too short to reach the cervix or vaginal apex. Lubrication with water or water-soluble lubricating jelly applied to the introitus or sides of the speculum eases insertion. If the patient is tender, 2% lidocaine jelly applied to the introitus, especially the posterior fourchette, will reduce sensation within 2 to 3 minutes. This is particularly useful for cognitively impaired women. If a pap smear is to be obtained, the jelly can be wiped away with a cotton swab. The vaginal walls should be inspected as the speculum is withdrawn whenever possible.

Bimanual examination is usually performed first with two fingers in the vagina, then with one in the vagina and one in the rectum. More information is obtained with the vaginal hand than the abdominal hand. Assess the size, orientation, and mobility of the cervix and uterus (if present), support of the vaginal apex, presence of any pelvic organ prolapse, and identification of any mass lesions. Rectal sphincter tone should be assessed, and the bulbocavernosus reflex can be tested if neurologic impairments are a consideration. Any palpable mass warrants additional evaluation. The presence and characteristics of stool in the rectal vault should be noted as this may be a clinical sign of constipation or other significant defecation disorder. A stool occult blood test may also be obtained. This requires changing gloves before the rectal examination if any bleeding occurred with speculum insertion or pap smear.

Benign Breast Disease

The breast is a complex structure subject to many pathological conditions, including ones affecting skin, muscle, nerves, ligaments, vasculature, and mammary ducts and alveoli. While numerous studies address the epidemiology of breast cancer and cancer precursors, little is known about the epidemiology of benign breast disease, especially in older women. Whereas fibrocystic changes in breast tissue are present asymptomatically in over half of older women, the prevalence of symptoms constituting “benign breast disease” is unknown. These usually present as a lump, pain, nipple discharge, or inflammation.

Breast Lump

Physical examination of the breast should not be completely supplanted by mammography, which can be negative in the setting of palpable tumors. Evaluation of a lump includes not only a description of the size, position, and character of the lump, but also documentation of pertinent negatives, such as lymph nodes, skin changes, and nipple discharge. All lumps should be evaluated by a surgeon or breast specialist, and a diagnostic mammogram should be obtained. Whether the mammogram is done before or after the surgeon sees the patient depends on the physicians and systems involved. If the patient complains of a lump not palpated by the physician, additional consultation is in order. If both the patient and physician agree that now there is no palpable abnormality, the patient should be asked to return in 2 months for reassessment.

Breast Pain

Breast pain is common and rarely indicative of dangerous pathology. It may be unilateral or bilateral, intermittent or persistent, and may or may not be associated with exogenous hormone therapy. Only half of women with significant breast pain seek medical attention. An important aspect of the history is the impact of the pain, such as inability to hug grandchildren, or awakening at night. Causes of pain originating in breast structures include fibrocystic disease, duct ectasia, trauma, sclerosing adenosis, and stretching of Cooper’s ligaments. Cancer uncommonly presents with breast pain, and mastalgia is not an indication for a diagnostic mammogram. However, surgical consultation is occasionally in order for focal persistent pain. Many conditions can be perceived as breast pain, such as costochondritis (Tietze’s syndrome), cervical radiculopathy, intercostal neuralgia, thrombophlebitis of the thoracepigastric vein (Mondor’s disease), herpes zoster, angina, cholecystitis, and hiatal hernia. Physical examination maneuvers to differentiate breast from chest wall pain include palpating the breast between both hands rather than putting pressure on the chest wall, and examination in the lateral recumbent position. If history and physical examination are benign, and mammographic screening for cancer is current, the patient can be offered reassurance and/or analgesics.

Nipple Discharge

Breasts always have the potential to secrete fluid, particularly if a woman has lactated previously. History and physical examination of nipple discharge should determine whether it is spontaneous or expressed, unilateral or bilateral, and involves single or multiple ducts. The color of the discharge and the presence of any mass should also be noted. Whereas unilateral, single-duct, spontaneous, bloody discharge holds the most concern, bilateral expressed discharge from multiple ducts does not indicate breast cancer. Many times the situation is between these two clear-cut extremes. A thick grumous or purulent discharge may indicate duct ectasia (dilated lactiferous ducts with inspissated secretions) or subareolar abscess. Duct ectasia is also the most common cause of blood-stained discharge from multiple ducts. If the discharge is white, an evaluation for hyperprolactinemia is in order, although this is rare in older women. Eczematous and other skin conditions may imitate nipple discharge. Most cases of spontaneous discharge necessitate referral.

Breast Inflammation

Inflammatory conditions intrinsic to the breast include duct ectasia, fat necrosis, foreign body, Mondor’s disease, radiation, and inflammatory carcinoma. Extrinsic conditions that may present with breast inflammation include metastatic lung cancer, Wegener’s granulomatosis, sarciodosis, and other skin diseases. Evaluation and referral will depend on the specific presentation.

Vulva

Examination of the Vulva

Age and estrogen deficiency may lead to loss of vulvar architecture, especially of the labia minora. Bartholin’s glands are located in the inferior (dorsal) aspect of each labium majus. Any mass, cystic or solid, in the area of the Bartholin’s gland should be referred to a specialist for additional evaluation. Usually these are excised to rule out carcinoma. Cherry angiomata and epithelial inclusion cysts on the labia are common and not concerning. Asymmetrical pigmented lesions should be noted and considered for either biopsy or follow-up examination.

Benign Conditions of the Vulva

Literally hundreds of disorders involve the vulva, generally falling into categories of infections, neoplasia, and dermatoses, which may reflect systemic disorders. Establishing clinically useful and pathologically appropriate nomenclature of vulvar disorders is challenging, and classification changes are not infrequent. The most recent classification of dermatoses by the International Society for the Study of Vulvovaginal Disease relies primarily on histologic morphology (Table 48-2). The vulva is more sensitive to allergens and irritants than other skin sites. Estrogen deficiency rarely causes symptoms, but may increase vulvar susceptibility to trauma, irritation, and secondary infection. A patient with “atrophic vaginitis” unresponsive to estrogen usually has a vulvar dermatologic condition. A very important part of the history is exactly what preparations, cleansing agents or routines a woman has employed to treat symptoms. Atopic, allergic contact, and irritant contact dermatitis may be caused by soaps, feminine hygiene products, or urine. A minor irritation can potentially be exacerbated into a severe irritant vulvitis with almost any topical preparation. Secondary infections with yeast and bacteria frequently occur whenever there is epithelial compromise, and must be treated along with the underlying condition. Ointments have fewer additives than creams and often cause less irritation.

Inflammatory Dermatoses of the Vulva

Benign inflammatory disorders of the vulva may be difficult to recognize, even by dermatologists, because the warm, moist, frictional environment alters the otherwise typical appearance of these entities. The lichenoid pattern dermatoses, lichen sclerosus and lichen planus, involve inflammation and disruption of basal epidermis.

Lichen sclerosus areas are typically white, bilateral, and relatively symmetrical with sharply demarcated borders, but may assume any configuration. White with a parchment-like surface is the most common appearance, but areas may be pink or red. With more advanced cases, vulvar architecture is lost. Labia minora may not be identifiable. The labia may be agglutinated anteriorly. A biopsy to confirm the diagnosis is helpful. The malignant potential of lichen sclerosus is debated, but may be as high as 4% to 5%. Areas should be inspected at least annually. Treatment is necessary only to control symptoms, most commonly pruritus. Regimens vary, generally involving aggressive topical steriods for a few weeks with each symptomatic flare, then steroid tapering, then a nonsteroid maintenance regimen. One option is to use clobetasol proprionate 0.05% ointment daily or bid for 1 to 2 months, then reduce the schedule over the next 1 to 3 months. Women often erroneously believe less medication is better, and should be encouraged to continue the steroids as prescribed until the itching is completely under control. Maintenance therapy probably reduces the frequency of symptomatic flares. Petroleum jelly, solid vegetable shortening, or other bland barrier ointment should be applied daily. When symptoms recur, steroids are reinitiated. Vaginal stenosis may occur in severe lichen sclerosus cases. Steroids, estrogen cream, dilators, and occasionally surgery may be useful to treat dyspareunia and sexual dysfunction.

New-onset autoimmune disorders of the vulva are uncommon in older women, but should be considered in the differential diagnosis of vulvar ulcers or rashes. Lichen planus may be associated with localized or generalized inflammation, which can be severe enough to cause introital stenosis. Other considerations include Zoon’s disorder (plasma cell vulvitis), Behçet’s disease, Crohn’s disease, aphthous ulcers, and Hailey-Hailey disorder (fragile and inflamed vulvar and axillary skin). Thickened epithelium is no longer called squamous hyperplasia, but is divided into psoriatic and lichen simplex chronicus categories. Psoriatic lesions of the genitalia do not exhibit the silver appearance seen elsewhere on the body, and are more often simply erythematous. There is usually a personal or family history of psoriasis. Lichen simplex chronicus may be primary or superimposed on other dermatoses. Medium to high-potency steroids are administered until symptoms are controlled, then maintenance therapy may be instituted.

Ulcerations and Infections of the Vulva

The differential diagnosis of genital ulceration includes a wide variety of sexually transmitted diseases, the most common of which in the United States is herpes simplex virus (HSV). A primary infection is usually associated with lymphadenopathy, vaginal discharge, urinary frequency, and painful ulcers on the labia and cervix. The incubation period is 2 to 12 days. Lesions clear in 2 to 3 weeks. Symptoms improve more quickly with the use of antiviral agents (e.g., acyclovir, famciclovir, valacyclovir). Frequent recurrences may require suppressive therapy. Immune suppression, including very advanced age, is a risk factor for HSV infection in the absence of sexual contact and for herpes zoster. Zoster of the S3 dermatome may inhibit detrusor function, and inability to void may be the presenting complaint. Condyloma acuminata may occur at any age, usually in association with human papillomavirus (HPV) from a new sexual contact. Biopsy of any raised lesion is appropriate if the diagnosis is in doubt.

Cancer of the Vulva

Vulvar cancer is the fourth most common malignancy of the female genital tract, accounting for 3% of all cases. The incidence of invasive vulvar cancer rises steadily with age, reaching 12 per 100 000 per year over age 80 years. Pruritus, pain, and a palpable lesion are typical presenting complaints, but particularly frail older women may not be aware of even a large lesion. Many women delay evaluation, leading to a worse prognosis (Table 48-3). Any focal, raised, irregular, or pigmented lesion warrants biopsy, which may be performed by the primary care physician without fear of causing spread. The most common vulvar malignancies are squamous cell carcinoma and malignant melanoma.

The incidence of vulvar carcinoma in situ increased 400% from 1973 to 2000, predominantly in women younger than 65 years. This parallels the increase in exposure to HPV. By contrast, the incidence of invasive vulvar cancer increased only 20% during this time. While HPV is the most common cause of vulvar carcinoma in situ and invasive vulvar cancer in younger women, only about half of invasive cancers are caused by HPV in women aged older than 65 years. The remainder may be associated with poor Langerhans cell function alone.