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common gynecological problems in the older woman

common gynecological problems in the older woman. Maggie H. Lee, MD Geriatrics Fellow Geriatrics Specialists of Lancaster Lancaster General Hospital February 19, 2013. DISCLOSURES. No commercial or financial disclosures. LEARNING OBJECTIVES.

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common gynecological problems in the older woman

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  1. common gynecological problems in the older woman Maggie H. Lee, MD Geriatrics Fellow Geriatrics Specialists of Lancaster Lancaster General Hospital February 19, 2013

  2. DISCLOSURES • No commercial or financial disclosures.

  3. LEARNING OBJECTIVES • Recognize current recommendations for cervical cancer screening and its cessation • Summarize differential diagnoses of vulvovaginaldermatoses and their management • Excluding cancers • Briefly discuss work-up of postmenopausal bleeding, focusing on excluding endometrial cancer

  4. CERVICAL CANCER SCREENING • A new 65 year old patient presents to your office to establish care. She is generally healthy. While discussing preventative healthcare, she inquires whether or not she will be getting her Pap smear done. There is no history of CIN2, CIN3, adeno-carcinoma in situ, nor cervical cancer. Her previous records show normal Pap smears 6 years ago, 8 years ago, and 9 years ago. • Should she be screened? If so, how often and how? • When can cervical screening stop?

  5. CERVICAL CANCER SCREENING • New 2012 recommendations! • 21 – 65 yo Pap test alone q 3 years (A) • 30 – 65 yo Pap test WITH HPV q 5 years (A) • 2.6% chance of normal Pap and (+) HPV in 60 – 65 yo • Recommends against screening > 65 yo who have had “adequate prior screening” and are not at high risk for cervical cancer (D) • 3 consecutive (-) cytology or 2 consecutive (-) HPV results within last 10 years with most recent test occurring within past 5 years • Can discontinue if >65 yoand no history of CIN2, CIN3, adenocarcinoma in situ, or cervical cancer and had 3 (-) Paps or 2 (-) HPV results in the last 10 years with most recent test in the last 5 years National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.

  6. CERVICAL CANCER SCREENING • A new 65 year old patient presents to your office to establish care. She is generally healthy. While discussing preventative healthcare, she inquires whether or not she will be getting her Pap smear done. There is no history of CIN2, CIN3, adeno-carcinoma in situ, nor cervical cancer. Her previous records show normal Pap smears 6 years ago, 8 years ago, and 9 years ago. • Should she be screened? If so, how often and how? Yes. 1 more time with Pap + HPV • When can cervical screening stop? If the next one is normal, she can stop after that.

  7. CERVICAL CANCER SCREENING • The previous patient returns to your office when she is 78 years old. Within the past 10 years, she has been sexually active with 5 different people. She is HIV negative. If she stopped getting Pap smears at the age of 66, • Should cervical cancer screening be re-initiated?

  8. CERVICAL CANCER SCREENING • New 2012 recommendations (continued) • Should NOT resume after cessation of screening in > 65 yo • Patients who have a history of cervical cancer, have HIV, are immunocompromised, or were exposed to diethylstilbestrol (DES) in utero should not follow routine screening guidelines. National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.

  9. CERVICAL CANCER SCREENING • The previous patient returns to your office when she is 78 years old. Within the past 10 years, she has been sexually active with 5 different people. She is HIV negative. If she stopped getting Pap smears at the age of 66, • Should cervical cancer screening be re-initiated? Not needed.

  10. CERVICAL CANCER SCREENING • A 68 year old postmenopausal woman comes to your office requesting her annual Pap Smear. She had a colposcopy with biopsies done at the age of 52 and a Loop Electrosurgical Excision Procedure done at the age of 53. She was told she had “cancer but they got it all, but needs yearly testing.” • How often should she be tested? • How should she be tested? • When can cervical cancer screening be stopped assuming subsequent testing is normal?

  11. CERVICAL CANCER SCREENING • New 2012 recommendations (continued) • Routing screening should continue x 20 years after spontaneous regression/management of high-grade precancerous lesions National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.

  12. CERVICAL CANCER SCREENING • A 68 year old postmenopausal woman comes to your office requesting her annual Pap Smear. She had a colposcopy with biopsies done at the age of 52 and a Loop Electrosurgical Excision Procedure done at the age of 53. She was told she had “cancer but they got it all, but needs yearly testing.” • How often should she be tested?At least every 3 years • How should she be tested?Pap q 3 years OR PAP+HPV-HR every 5 years • When can cervical cancer screening be stopped assuming subsequent testing is normal? At the age of 53+20 = 73

  13. CERVICAL CANCER SCREENING • What if the patient’s next routine screening results showed ASCUS with negative HPV-HR? • What if the patient’s next routine screening results showed normal Pap with positive HPV-HR?

  14. CERVICAL CANCER SCREENING (cont’d) • New 2012 recommendations (continued) • Co-testing should NOT be performed in those < 30 yo. • For those 30+ yo: (+)HPV and (-) Pap or Genotype for HPV 16+18 Repeat co-testingin 12 months neg Not -/- neg pos NOTE: ASCUS with (-)HPV should return to routine screening colposcopy Back to routine screening National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.

  15. VULVOVAGINAL DERMATOSES A 69 year old patient, who has had UTIs at least every year for the past 5 years, comes to the office because she has vulvar burning, itching, and soreness. She does not complain of discharge. However, on preliminary examination, there is slight introitalstenosis, loss of vaginal rugae, flattening of the labia architecture, slight urethral telescoping, and a slight yellow vaginal discharge. • What do you do next? • Do you have a final diagnosis? Modified from Geriatrics Review Syllabus. 7th edition.

  16. VULVOVAGINAL DISCHARGE

  17. VULVOVAGINAL DISCHARGE

  18. PHYSIOLOGY • Menopause: • Urogenital:  blood flow,  tissue oxygenation

  19. Workflow of pH paper use for confirming Vulvovaginal Atrophy at GSL and WLAFHC Patient > 65 yo or menopausal (naturally or surgically)? No Yes No further action Complains of… None of the symptoms listed to the right > 1 of following symptoms: • h/o recurrent UTI with • urinary frequency OR • urinary urgency OR • dysuria • urinary incontinence • dyspareunia • vaginal dryness • vaginal discharge • encounter for Pap/gyn exam and • Have patient changed into gown for pelvic exam. • Place pH strip in middle vagina on lateral wall for 5 seconds • Perform wet prep if indicated. • Perform whiff test if + discharge. • Place pH strip in middle vagina on lateral wall for 5 seconds prior to urination. • Obtain U/A

  20. VULVOVAGINAL DISCHARGE

  21. VULVOVAGINAL DERMATOSES A 69 year old patient, who has had UTIs at least every year for the past 5 years, comes to the office because she has vulvar burning, itching, and soreness. She does not complain of discharge. However, on preliminary examination, there is slight introitalstenosis, loss of vaginal rugae, flattening of the labia architecture, slight urethral telescoping, and a slight yellow vaginal discharge. • What do you do next? Analyze the vaginal discharge, diagnose vaginal atrophy. • Do you have a final diagnosis? Possibly... Modified from Geriatrics Review Syllabus. 7th edition.

  22. VULVOVAGINAL DERMATOSES On further examination, there is evidence of vulvar scarring, glassy erythematous erosions, white striae along the margins of the labia minora an vestibule, and vaginal involvement. A specimen is obtained for biopsy. Which of the following is the most likely diagnosis? • Vulvar Dermatitis • Lichen sclerosus • Lichen simplex chronicus • Lichen planus Geriatrics Review Syllabus. 7th edition.

  23. BASIC DIFFERENTIAL

  24. VULVOVAGINAL DERMATOSES On further examination, there is evidence of vulvar scarring, glassy erythematous erosions, white striae along the margins of the labia minora an vestibule, and vaginal involvement. A specimen is obtained for biopsy. Which of the following is the most likely diagnosis? • Vulvar Dermatitis • Lichen sclerosus • Lichen simplex chronicus • Lichen planus Geriatrics Review Syllabus. 7th edition.

  25. EXTENDED DIFFERENTIAL

  26. BIOPSYING TIPS • Adequate anesthesia: 2% lidocaine with epi • Biopsy primary lesions • Have a differential in mind or the pathology may not help • Thick/raised area  get thickest area, 4 mm punch • Erosions/scarring  look for fresh non-traumatized skin and may want to get viral cultures • Blister  biopsy NEXT to it • Ulcer/erosion  4 mm punch at leading edge and around • If multiple biopsies, start at the bottom and move up. • Multiple biopsies for multifocal disease

  27. TREATMENT • Vulvar hygiene • Super potent steroid then decrease to mild potent steroid for maintenance • “Rule of Two’s” • Clobetasol 0.5% ointment BID x 2 months • Then QHS x 2 months • Then PRN x 2 weeks at a time for flares and place on maintenance mid potency 0.025 – 0.1% triamcinolone cream • How big of a tube? • Finger Tip Unit = 2 handprint’s ~ 0.5 g • 45 g of 2 months BID should last 2 – 12 months • Schedule return visits in 1 – 2 months

  28. STEROID COMPLICATIONS to AVOID • Suppression of hypothalamic pituitary adrenal axis: • Continuous topical application of 90g/month of superpotent steroid can • Osteopenia • Cataracts • Rebound dermatitis • Candida superinfection • 2% ketoconzole lotion or cream • Diflucan 150mg weekly x 2 – 4 months then monthly at least 4 months

  29. WHEN TO REFER • Not healing with steroids • Correct diagnosis? • Poor symptom control • > 30g/6 months or use > 3x/week • Presence of irregular white plaques, erosions, ulcers, and NO atrophy • Previously treated for VIN/vulvar SCC • Localized skin thickening/hyperkeratosis • Biopsies where differentiated VIN possible

  30. POSTMENOPAUSAL BLEEDING Which of the following is the most likely cause of new onset vaginal bleeding in a 70 year old woman? • Endometrial cancer • Endometrial hyperplasia • Pyometria • Vaginal atrophy • Hormonal effect GRS. 7th edition.

  31. ENDOMETRIAL CANCER • 4th most common cancer in women in U.S. • 90% occur in > 50 yo • 95% Type 1 associated with estrogen exposure  endometrial hyperplasia • 5% Type 2 not associated with estrogen exposure

  32. ENDOMETRIAL CANCER • Pap: • “benign endometrial cells”  further eval • No Level A approach from ACOG • No benefit in screening • unless risk for HNPCC • History & Physical • BMI, pelvic exam (uterus size) • Bloodwork • Urine preg • Rule out STDs • CBC, TSH, LFTS • PTT/INR, vWF • Pap?

  33. ENDOMETRIAL CANCER or or or

  34. POSTMENOPAUSAL BLEEDING • ACOG Committee Opinion 8/2009 • Women with postmenopausal uterine bleeding may be assessed initially with either endometrial biopsy or transvaginalultrasonography; this initial evaluation does not require performance of both tests, • If tissue from endometrial biopsy is insufficient for diagnosis, further investigation is necessary and TVUS may be performed. • IF TVUS is performed, and an endometrial thickness of < 4 mm is found, endometrial sampling is not required. • The significance of an endometrial thickness of >4 mm in an asymptomatic, postmenopausal patient has not been established.

  35. APPENDIX • References • Geriatric Pelvic Exam Tips • Vulvar Dermatitis: Common irritants and allergens • Vulval Hygiene • Topical Steroids: Potency Chart • Topical Steroid Cross-Reactivity • Sensitivity and Specificity of Vaginal Discharge/Tests • Candidal Vaginitis • Vulvovaginal Atrophy

  36. References • American Geriatrics Society. (2010). Gynecologic diseases and disorders. In Pacala JT and Sullivan GM (Eds.) Geriatrics Review Syllabus 7th edition. 468–73. New York. • Beecker J. Therapeutic principles in vulvovaginal dermatology. DermatolClin, 2010. 28: 639–48. • Biggs WS and Williams RM. Common gynecologic infections. Prim Care Clin Office Pract, 2009. 36: 33–51. • Buchanan EM et al. Endometrial cancer. AAFP, 2009. 80(10): 1075 – 80. • Carter JS and Downs, Jr LS. Vulvar and vaginal cancer. Ob GynClin N Am, 2012. 39: 213–31. • Edwards L. Dermatologic causes of vaginitis: a clinical review. DermatolClin, 2010. 28: 727–35. • Gerten KA et al. Benign gynecologic disorders in the older woman. In Rosenthal RA et al. (Eds.) Principles and Practice of Geriatric Surgery 2nd edition. 1083–97. New York. • Lentz SS and Homesley HD. Gynecologic problems in older women. Clinics Geri Med, 1998. 14(2): 297–315. • McKay M. Vulvar disease. 56th T. Har Baker, MD, Obstetrcis and Gyencology Symposium. Audio Digest, 2012: 59(23). • Mehta A and Bachmann G. Vulvovaginal complaints. Clin Ob Gyn, 2008. 51(3): 549–55. • Moroney JW and Zahn CM. Common gynecologic problems in geriatric-aged women. Clin Ob Gyn, 2007. 50(3): 687–708. • Pastore LM et al. Vaginal symptoms and urinary incontinence in elderly women. Geriatrics, 2007. 62(7): 12–18. • Policar MS. Office gynecology: Managing common concerns in women. 2011 UCSF Family Medicine Board Review. Audio Digest, 2012. 60(10). • Olsson A et al. Postmenopausal vulval disease. Menopause Int, 2008. 14(4): 169–72. • Quan M. Vaginitis: diagnosis and management. Postgrad Med, 2010. 122(6): 117–27. • Saunders NA and Kaefner HK. Vulvar lichen sclerosus in the elderly. Drugs Aging, 2009. 26(1): 803–12. • Practice Bulletin: Screening for Cervical Cancer. Obst & Gyn, 2012. 120(5): 1222 - 1238. • Schorge JO et al. Abnormal uterine bleeding. In Williams Gynecology 1st and 2nd edition. New York. • Stiles M et al. Gynecologic issues in geriatric women. J Wom Health, 2012. 21(1): 4–9. • Torres MR and Canto G. Hypersensitivity reactions to corticosteroids. CurrOpin Allergy ClinImmunol, 2010. 10(273).

  37. GERIATRIC PELVIC EXAM TIPS • Performing pelvic exam: • Narrow-blade speculum • Use 1 finger for bimanual • Frog-leg position • + inverted bedpan covered by towel • Use speculum upside down • Left lateral decubitus position, assistant holds right leg up • If with introital/cervical stenosis, topical estrogen x 1 – 2 weeks prior to speculum exam • May use cytobrush or dilators/sounds to help dilate cervix prior to endometrial biopsy

  38. Vulvar Dermatitis

  39. Vulval Hygiene

  40. Topical Steroids: Potency Chart Adapted from www.psoriasis.org

  41. Topical Steroids: Potency Chart (cont’d) Adapted from www.psoriasis.org

  42. Topical Steroid Cross-Reactivity Adapted from: Torres MJ and Canto G.

  43. Sensitivity and Specificity of Vaginal Discharge/Tests VulvovaginalCandidiasis Bacterial Vaginosis Trichomonas

  44. CandidalVaginitis • Refractory cases: • Fluconazole 150mg x 3 q 72 hours • Topical azole therapy for 1 – 2 weeks • Recurrent cases (> 4 symptomatic cases /yr) • Fluconazole 150mg x 3 q 72 hours then weekly • May also use itraconazole or terbinafine • Prophylaxis: • If starting estrogen, • Fluconazole 150mg PO q week x 5 weeks or • Nystatin ointment compounded in estrogen or • Azole cream compounded in estrogen • If starting on antibiotics

  45. Vulvovaginal Atrophy • Treatment • Hormonal 3x/week • Topical estrogen >> systemic • 10 – 25% women will continue to experience symptoms with systemic estrogen • Vaginal Ring: Estring • Vagifem tablets: 10 or 25 mcg nightly • Estrace/Premarin Cream: 1 g

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