Gynecologic Issues in Geriatric Women

Abstract

The number of women over the age of 65 is projected to almost double in the next 20 years, and clinicians need to be comfortable treating conditions common to this cohort. This review covers several common gynecologic conditions seen in older women, including atrophic vaginitis, lichen sclerosis, pelvic floor disorders, and postmenopausal bleeding. We conclude with evidence-based screening recommendations for gynecologic cancers in older women and tips on doing a pelvic examination.

Introduction

There were almost 40 million adults over the age of 65 in 2009. This population is expected to increase to 72 million by 2030.¹ Thus, clinicians need to be familiar with common complaints of older adults. This article reviews common gynecologic conditions seen in older women, cancer screening guidelines, and discussion of special issues in doing pelvic examinations in older women.

Atrophic Vaginitis

Atrophic vaginitis is a series of physiologic and structural changes in the vulovaginal mucosa secondary to a hypoestrogenic state. This is a common occurrence in postmenopausal women and is also found in patients who have undergone breast cancer treatment, lactation, or occasionally with use of certain medications. Although mild genital changes occur in most postmenopausal women, a significant number of women will develop the more important changes associated with atrophic vaginitis, including vaginal dryness, itching, soreness, pain, dyspareunia, urinary frequency, urgency, incontinence, and recurrent urinary tract infections (UTIs).² The prevalence of atrophic vaginitis has been examined in several studies, including one longitudinal study that estimated 4% of early perimenopausal and 47% of late postmenopausal women with symptoms.³ For most women, atrophic vaginitis worsens as they age because of persistence of hypoestrogenism.

Extensive physiologic effects of hypoestrogenism are noted throughout the female urogenital tract because the squamous epithelium, connective tissue, and smooth muscle all have estrogen receptors (ERs). With the loss of estrogen, there is an overall loss of mucosal elasticity^4,5 and a decrease in hygroscopic compounds, which leads to vaginal dryness and a subsequent loss of mucosal epithelium.^4,6,7 In premenopausal woman, epithelial cells continuously exfoliate and die, releasing glycogen, which is hydrolyzed to glucose. Glucose, in turn, is broken down into lactic acid by the action of Lactobacillus, a normal vaginal organism. With the thinning of the epithelium, this cascade does not occur, and the pH in the vagina rises in postmenopausal women, resulting in a loss of lactobacilli and an overgrowth of other bacteria. This can lead to chronic infections or low-grade inflammation. Hypoestrogenism also leads to a decline in vaginal blood flow and a decrease in natural lubrication.⁸

Atrophic vaginitis is generally a clinical diagnosis. On physical examination, women with atrophic vaginitis often will have atrophy of the mons and labia majora and minora. The vulvar and vaginal epithelium will typically appear pale and dry, and petechiae may be present. With chronic inflammation from infection or other dermatoses, the introitus and mucosa may appear reddened. Over time, the vaginal rugae disappear, and the cervix can appear flat against the vaginal wall. Women may also experience a narrowing or shortening of the vagina, and a urethral caruncle may develop.^2,4 Vaginal pH may be used to support physical examination findings. Using litmus paper, a pH ≥4.6 indicates atrophy, assuming the patient does not have bacterial vaginosis. Premenopausal women typically have a pH of ≤4.5.^4,9

One of the most common and troubling symptoms for women with atrophic vaginitis who are sexually active is dyspareunia. Treatment includes nonhormonal vaginal moisturizers, lubricants, and hormonal creams and supplementation. For women with mild vaginal atrophy symptoms, vaginal moisturizers with lubricants during intercourse are recommended. Vaginal moisturizers are typically water-based creams or gels that shift the pH in the vagina to the more acidic, premenopausal state. Many are used on a chronic, long-term basis to replace normal vaginal secretions. All products moisten the epithelium and slowly release water and electrolytes into the tissue. Additionally, some vaginal commercial preparations are available and are applied with or without an applicator.⁴

Vaginal lubricants are applied for comfort and to reduce friction only at the time of sexual intercourse. These products are typically water or silicone based. They are short acting and do not alter the vaginal moisture or pH. Sexual activity may encourage vaginal elasticity and pliability and the lubricative response to sexual stimulation. Women who participate in sexual activity report fewer symptoms of atrophic vaginitis in comparison with sexually inactive women.¹⁰

Estrogen replacement is the most effective therapy for treating moderate to severe symptoms of atrophic vaginitis and for those in whom moisturizers and creams have not been effective. Estrogen replacement can be systemic or local. Although systemic estrogen therapy can improve vulvovaginal complaints, approximately 10%–25% of women using systemic estrogen preparations will continue to experience debilitating urogenital symptoms, requiring additional vaginal therapy for relief.¹¹ Many women prefer local therapy because compared to oral estrogen doses, low estrogen doses can be used to achieve favorable changes in the vaginal epithelium while avoiding or minimizing systemic effects. On the basis of a meta-analysis of 19 randomized controlled trials (RCTs) involving 4162 postmenopausal women, the 2006 Cochrane Database of Systematic Reviews concluded that vaginal estrogen is an effective treatment for atrophic vaginitis and that all forms, whether cream, ring, or tablet, appeared to relieve symptoms more effectively than did nonhormonal gels and placebo^4,11 (Table 1). Differences observed between the treatments were in participant preferences. Although the primary effects of topical estrogen are local, some systemic absorption does occur. Patients should not be prescribed vaginal estrogens if they have undiagnosed vaginal bleeding, current breast cancer, history of endometrial cancer, liver failure, or a thromboembolic disorder or are pregnant or breastfeeding. In particular, there is concern that this may lead to endometrial proliferation, although there are no recommendations to support the addition of progestins. A progestin is not necessary to protect against endometrial hyperplasia in women receiving daily local low-dose estrogen (0.3 mg conjugated estrogen) for vaginal atrophy. A progestin should be considered when estrogen doses are above this level.¹² Further endometrial evaluation is advised if bleeding occurs with any form of estrogen supplementation.

Table 1.

Estrogen Preparations for Treatment of Atrophic Vaginitis

Preparation	U.S. trade name	Active component and strength	Approved dosing regimen
Cream	Premarin	Conjugated estrogens 0.625 mg/g	0.5–1.0 g cream (maximum 2.0) PV daily for 7 days, then twice weekly
Cream	Estrace^a	Estradiol 0.1 mg/g	0.5–4.0 g cream for 1–2 weeks, then twice weekly
Vaginal tablets	Vagifem	Estradiol 10 μg	1 tablet PV daily for 2 weeks, then twice weekly
Vaginal ring	Estring^b	Estradiol 7.5 μg/24 h (6–9 μg)	Self-insert ring into upper third of vagina, replace in 90 days
Vaginal ring	Femring^c	Estradiol 50 μg/24 h or 100 μg/24 h	Self-insert ring into upper third of vagina, replace in 90 days

If using >4.0 g of Estrace, endometrial evaluation is recommended.

It is estimated that 10% of estradiol is absorbed systemically with the Estring.

The Femring is approved for the treatment of vasomotor and genitourinary symptoms due to high dose and systemic absorption.

PV, per vagina. Typically best applied before sleep.

Lichen Sclerosus

Vulvar lichen sclerosus (LS) is a benign chronic inflammatory skin condition that is diagnosed mainly in postmenopausal women but may affect women of all ages. It was first described in 1887 by Dr. Hallopeau in France.¹³ The disease can range from asymptomatic skin lesions to permanent scarring and pain. Although the prevalence of LS is unknown, up to 1 in 30 elderly women may have the condition. The etiology of LS is also unknown; genetic, autoimmune, infections, and local factors have all been implicated. Up to 34% of patient with LS have an associated autoimmune disease, the most common being pernicious anemia, vitiligo, thyroid disease, and alopecia areata.¹⁴ Infectious agents, particularly Borrelia burgdorferi, have been associated with LS in European studies but not in the United States.^15,16 As the prevalence of LS increases after menopause, low estrogen levels with associated atrophy may play a role in the etiology. Of concern is the association of LS with squamous cell cancer of the vulva. The frequency of associated squamous cell cancer is around 4.5%. Cancer develops after an average duration of 10 years from the onset of LS.¹⁷

Clinically, the most common symptoms of LS are vulvar irritation and pruritis. The symptoms are particularly worse at night, often leading to sleep disturbance. As the disease progresses, scratching can lead to lichenification, erosions, and fissures. Because the disease can involve the anus, patients can also experience pruritis ani, rectal bleeding, and dyschezia. Involvement of the labia minora and introitus can cause dyspareunia and dysuria. The initial lesions are characterized by ivory white plaques with a crinkled texture and are often accompanied by atrophy, hemorrhage, and ecchymoses from irritation (scratching).¹⁸ The differential diagnosis includes lichen planus, lichen simplex chronicus, psoriasis, and vitiligo.

LS is a clinical diagnosis that can be aided by biopsy. Histologically, LS usually appears as a homogenized edematous papillary (upper) dermis and an effaced epidermis. Experts disagree whether to biopsy lesions in everyone or just in those who do not respond to therapy.¹⁸ Biopsy can help differentiate LS from lichen planus, lichen simplex chronicus, and psoriasis. Of note, as the pathology for LS is often difficult to interpret; a nonspecific biopsy does not rule out the disease, and the decision to treat should be based on clinical findings.¹⁹

The first-line treatment of LS is a high-potency topical steroid. It is important to note that there is a lack of RCTs for the treatment of LS and that the treatment frequency and duration are based on opinion and consensus guidelines.²⁰ A suggested regimen is clobetasol propionate ointment daily for 1 month, then every other day for 1 month, then one to two times weekly for maintenance therapy.²¹ Successful treatment is characterized by resolution of symptoms and some skin changes (hyperkeratosis, fissuring, and ecchymoses). Atrophy and scarring will not change with treatment. Intralesional steroids can be used for larger plaques.²² Other treatments under investigation include androgens, topical immunomodulators (tacrolimus and pimecrolimus), retinoids, and photodynamic therapy. Patients should be referred to specialists if they have recalcitrant lichenification or hyperplasia on biopsy, as this subgroup is at higher risk of malignancy.²³

Pelvic Floor Disorders

Pelvic floor disorders affect almost 24% of women. The prevalence increases with age, parity, and obesity.²⁴ Pelvic floor dysfunction is associated with a decreased quality of life secondary to urinary incontinence, fecal incontinence, defecatory dysfunction, and pelvic organ prolapse. One study reviewing health maintenance organization (HMO) records of over 2000 women with a mean age of 61 demonstrated that older women had 10 times the number of consultations for pelvic floor disorders as did younger women.²⁵

The pelvic organs are supported by an interconnected network involving the uterosacral/cardinal ligaments, the levator ani muscles, and the endopelvic fascia. Damage to any of these structures can lead to disorders of the pelvic floor. Age-related changes to connective tissues and neuromuscular structures likely explain the increasing prevalence of pelvic floor dysfunction in older women. The demand for pelvic floor services is projected to grow at twice the rate of the population in the next few decades.²⁶ Primary care physicians can expect to see more complaints of pelvic organ prolapse, urinary incontinence, and defecatory dysfunction in their offices.

Risk factors for pelvic floor dysfunction include genetic predisposition, increasing parity, operative vaginal delivery, obesity, advancing age, estrogen deficiency, prior pelvic surgery and connective tissue disorders.²⁷ Women with pelvic floor disorders typically experience pelvic organ prolapse or dysfunctional bowel or bladder evacuation. Within the general population, 16% of women will have urinary incontinence, 9% will have fecal incontinence, and 3% will have pelvic organ prolapse. Women who have poor posterior or central pelvic floor support also often have symptoms of obstructed defecation (straining without successfully defecating, a sense of inability to expel stool, or chronic pelvic pain with bowel movements).²⁶

The most common symptom of pelvic organ prolapse is a sensation of pelvic pressure or protrusion. Patients may describe feeling like they are sitting on an egg or complain of low back heaviness or pain. The discomfort worsens over the course of a day, is improved in a supine position, and worsens with vigorous activity.²⁸ Urinary symptoms can range from stress incontinence (secondary to loss of anterior vaginal support) to urinary retention (due to ureteral kinking from vaginal vault eversion). Defecatory symptoms are common and can occur from a rectocele. When severe, patients may have to manually splint the posterior vagina in order to have a bowel movement. Many patients with any type of prolapse have difficulty with intercourse.

Pelvic organ prolapse refers specifically to herniation of one of the pelvic organs (uterus, small bowel, vaginal apex, bladder, or rectum and its associated vaginal segment) away from the normal position. The degree of displacement is graded from 0 to 4: 0, no prolapsed; 1, midway to the hymen; 2, to the hymen; 3, halfway out of the hymen; 4, total prolapse (procidentia). Evaluation of pelvic organ prolapse is done via physical examination. The examination should include evaluation both in the dorsal lithotomy position and upright in a standing position. During the speculum examination, each area of the vagina should be evaluated, which can be done with a single blade speculum. The upright portion of the examination involves the patient standing with one leg elevated on a footstool. The examiner should then do a standing pelvic examination with the patient at rest and with the Valsalva maneuver. The best method for finding an enterocele is a rectovaginal examination.

A 2006 Cochrane Review looked at three modalities for management of pelvic organ prolapsed—conservative treatment (physical interventions and lifestyle changes), no treatment, or other (surgery or other mechanical devices)—and found that there is not enough evidence to support one modality over another. There was some early evidence that outpatient pelvic floor muscle training could reduce the severity of prolapse.²⁹ Management should be guided by the severity of both symptoms and degree of prolapse. In obese patients, weight loss can be beneficial. In patients with mild to moderate prolapsed, pelvic floor exercises, physical therapy, and behavioral modifications, that is, timed voiding and defecation and diet changes, often are beneficial. Moderate prolapse can be managed with a pessary. Surgery is generally recommended for severe prolapse. A 2007 American College of Obstetricians and Gynecologists (ACOG) practice bulletin made treatment recommendations for pelvic organ prolapse³⁰ (Table 2).

Table 2.

Evidence-Based Treatment for Pelvic Floor Disorders

Level A evidence (based on good and consistent scientific evidence)

The only symptom specific for prolapse is awareness of a vaginal bulge/protrusion. For any other pelvic symptoms, resolution with prolapse treatment cannot be assumed.

Pessaries can be fitted in most women with prolapse regardless of stage or site of prolapse.

Level B evidence (fair evidence)

Clinicians should discuss pessary use with all women with symptomatic prolapse. Pessary use should be considered before surgical intervention.

Level C evidence (primarily based on consensus and expert opinion)

Women with prolapse with no or mild symptoms can be observed.

Postmenopausal Bleeding

Menopause is defined as 12 months without a menstrual period as the result of a depletion of ovarian follicles and, thus, is a retrospective diagnosis. After the year without menstrual bleeding, any further bleeding is abnormal. A large Danish study found a 10% prevalence of postmenopausal bleeding.³¹ Bleeding episodes decreased as the time since menopause increased in this study. The main concern in a postmenopausal woman with bleeding is endometrial carcinoma. Between 10% and 20% of all postmenopausal bleeding will be due to malignancy,³² and the risk of malignancy increases with age and time since menopause. According to the American Cancer Society, there would be 43,470 new uterine cancers diagnosed in 2010, accounting for 7950 deaths.³³

Aside from endometrial cancer, there are many causes of postmenopausal bleeding, including endometrial hyperplasia and atrophic changes (Table 3). The goal of evaluation is to exclude malignancy and determine if the cause of the bleeding is treatable. Women on hormone therapy (HT) may have abnormal bleeding for several months after initiation of the medication.

Table 3.

Causes of Postmenopausal Bleeding

Diagnosis	Evaluation
Endometrial carcinoma	Found on endometrial biopsy; consider if endometrium is thick on ultrasound
Atrophic vaginitis	Diagnosed by examination; symptoms improve with vaginal estrogen
Endometrial polyp	May have abnormal endometrial thickness on ultrasound; often visualized with saline-infused ultrasound or hysteroscopy
Atrophic endometritis	May be seen on endometrial biopsy
Hormone therapy	History consistent with use of hormone therapy; other evaluation negative
Endometrial hyperplasia	Usually diagnosed with endometrial biopsy; may have abnormal ultrasound
Trauma	History consistent with pelvic trauma
Cervical polyp	Usually seen on vaginal examination
Other genital tract malignancy (i.e., vaginal)	Usually seen on vaginal examination

Evaluation of postmenopausal bleeding can be done effectively with either a pelvic ultrasound examination or an office endometrial biopsy. A transvaginal ultrasound can assess the thickness of the endometrium. A thickness of <4 mm in diameter has been the standard cutoff to exclude endometrial cancer.³⁴ Women with an endometrial thickness of <4 mm have a very low risk of malignancy (about 1 in 900).³⁵ A recent meta-analysis, however, suggests that lowering the cutoff to 3 mm may be a more prudent clinical parameter in order to exclude endometrial cancer.³⁶ An office endometrial biopsy is a good diagnostic test to evaluate endometrial tissue but does not always sample the entire cavity and may not evaluate polyps.^37,38 However, in some postmenopausal women, cervical stenosis precludes a successful biopsy. In this situation, if the ultrasound is nonreassuring (i.e., demonstrates an endometrial stripe of >3–4 mm), a surgical procedure, such as a hysteroscopy or dilatation and curettage, may be indicated to obtain a sample of the endometrium. In addition, saline-infused ultrasound may provide greater clarification of the endometrium and can be a valuable addition to the evaluation, especially if an endometrial polyp is under consideration as the cause of bleeding. If cervical stenosis is present, however, a saline-infused ultrasound may not be possible, and a surgical procedure may be necessary to sample and assess the endometrium.

Cancer Screening Guidelines

The recent ACOG guidelines on cervical cancer screening provide an evidence-based review of cervical cancer screening practices.³⁹ In postmenopausal women who have been screened routinely during their lives and have not had an abnormal screen within the past 20 years, it is appropriate to discontinue screening at age 65 or 70. Women who have a previous history of dysplasia should continue screening for 20 years after their last abnormal screen. Women who have had a hysterectomy for a nonmalignant cause do not need further Pap smear screening.⁴⁰ There is no evidence that screening for ovarian cancer with either Ca-125, pelvic ultrasound, or pelvic examination affects mortality from that cancer.⁴⁰ The U.S. Preventive Services Task Force (USPSTF) in 2004 gave a D recommendation to any type of screening for ovarian cancer, stating that screening programs actually caused more harm than good.

As mentioned, any women with postmenopausal bleeding should be evaluated carefully for uterine cancer. However, there is no reliable screening test for uterine cancer in asymptomatic women, and no evidence exists to support the routine use of screening pelvic examination to screen for cancer in asymptomatic older women.⁴¹

Pelvic Examination in Geriatric Women

The gynecologic examination in the geriatric patient is essentially the same as in the younger adult but may need to be modified to account for physical limitations, the physiologic changes of aging, and the increased incidence of prolapse. If patients are unable to tolerate the dorsal lithotomy position, there are two alternatives. One is the frog-leg position, where the patient lies on her back, bends her knees with heels together, and then abducts the knees. For better visualization, an inverted bedpan covered by a towel can be placed under the sacrum. The speculum is used upside down in this position. The second is the left lateral decubitus position, where an assistant holds the right leg up to facilitate the examination.⁴²

Atrophic vaginitis often causes a stenotic introitus, friable tissue, and a shortened vaginal vault. If a speculum examination is still indicated, use of a narrow-blade Pederson speculum or virginal speculum is indicated. The pelvic examination often needs to be modified to a one-finger examination in patients with significant atrophic vaginitis. For patients who are obese or have significant prolapse or tissue relaxation, the wide-blade Graves speculum may be needed.⁴²

The speculum examination is indicated if the woman is still a candidate for screening or if she has such symptoms as pelvic organ prolapse, vaginitis, incontinence, or postmenopausal bleeding, which warrant an examination. ACOG recommends annual pelvic examinations over the age of 65 unless the women have had a total hysterectomy and bilateral oophorectomy for benign reasons. As there is questionable utility in performing a pelvic examination in an asymptomatic woman, clinicians need to consider the patient's life expectancy and comorbities when deciding to continue annual examinations.^43,44

Footnotes

Disclosure Statement

The authors have no conflicts of interest to report.

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