A 48-year-old woman comes to the clinic due to dyspareunia, which has worsened over the last 4 months. Five years ago, the patient underwent radiation and chemotherapy for stage II cervical cancer. She has not been sexually active for several years due to fear of cervical cancer recurrence. Now the patient has a new partner and is using over-the-counter lubricants during intercourse but still experiences pain with penetration. She has had no postcoital bleeding, dysuria, or abnormal vaginal discharge. The patient has a 20-pack-year smoking history. She has not had a menstrual period since completing radiation therapy. Vital signs are normal. Examination shows thin vulvar skin with shrinkage of clitoral tissue. The vaginal introitus is narrow, and the vaginal mucosa appears pale. The cervix appears scarred consistent with postradiation changes but has no raised, nodular, or friable lesions. Which of the following is the most likely cause of this patient's condition?

Question

A 48-year-old woman comes to the clinic due to dyspareunia, which has worsened over the last 4 months.  Five years ago, the patient underwent radiation and chemotherapy for stage II cervical cancer.  She has not been sexually active for several years due to fear of cervical cancer recurrence.  Now the patient has a new partner and is using over-the-counter lubricants during intercourse but still experiences pain with penetration.  She has had no postcoital bleeding, dysuria, or abnormal vaginal discharge.  The patient has a 20-pack-year smoking history.  She has not had a menstrual period since completing radiation therapy.  Vital signs are normal.  Examination shows thin vulvar skin with shrinkage of clitoral tissue.  The vaginal introitus is narrow, and the vaginal mucosa appears pale.  The cervix appears scarred consistent with postradiation changes but has no raised, nodular, or friable lesions.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d9b9_015e_bc81_5335a467d625_MD0003_00 This patient has atrophic vaginitis (or the genitourinary syndrome of menopause) from medically-induced menopause due to radiation and chemotherapy treatment for cervical cancer resulting in ovarian follicle depletion. Estrogen maintains the moisture, blood flow, and collagen content (eg, elasticity, turgor) of the vulvovaginal tissues (eg, vagina, vulva, urethra). Patients with low estrogen levels eventually develop dryness and decreased blood flow and elasticity in these estrogen-dependent tissues. Symptoms of estrogen deficiency are due to thinning of the vulvar skin (eg, irritation), narrowing of the vaginal introitus (eg, dyspareunia), and loss of natural lubrication (eg, dryness). Physical examination findings include pale, easily-denuded, retracted, atrophic vulvovaginal epithelium (eg, clitoral shrinkage). First-line treatment includes over-the-counter lubricants or moisturizers. Persistent or severe symptoms are treated with vaginal estrogen. (Choice B) Lichen planus is a chronic, inflammatory skin dystrophy that results in glazed, brightly erythematous, vulvar lesions with a purple hue that may be overlaid by white reticular lines (ie, Wickham striae). (Choice C) Patients with lichen sclerosus have thin, wrinkled vulvar skin that can form into thickened white plaques that eventually obliterate the labia majora and minora, scarring the normal external landmarks. In contrast to atrophic vaginitis, lichen sclerosus does not affect the vagina. lichen sclerosus (Choice D) Recurrent cervical cancer typically presents with abnormal bleeding from raised, friable cervical nodules (not seen in this patient). (Choice E) Vulvar intraepithelial neoplasia (VIN) creates asymptomatic or pruritic vulvar lesions, particularly in smokers. VIN typically appears as raised, multifocal vulvar lesions (eg, white, erythematous, hyperpigmented), which are not seen in this patient. (Choice F) Vulvodynia causes dyspareunia due to a sharp, burning pain on the vulvar vestibule often triggered by touch (eg, positive Q-tip test). Patients may have vestibular erythema but no associated vaginal tissue narrowing or clitoral tissue shrinkage. Educational objective: Atrophic vaginitis (genitourinary syndrome of menopause) is due to low estrogen levels, which cause decreased vulvovaginal tissue elasticity and blood flow. Patients may have resultant dyspareunia due to narrowing of the vaginal introitus and dryness from loss of natural lubrication. Treatment is with lubricants or moisturizers; vaginal estrogen is used for persistent or severe symptoms. References: Vulvar and vaginal atrophy: physiology, clinical presentation, and treatment considerations. (http://www.ncbi.nlm.nih.gov/pubmed/26125962) Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. (http://www.ncbi.nlm.nih.gov/pubmed/25155380) ACOG practice bulletin no. 141: management of menopausal symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/24463691)

A 48-Year-Old Woman Comes to the Clinic Due to Dyspareunia