A 49-year-old woman comes to the office for evaluation of decreased interest in sexual intercourse for the past 6 months. The patient has been married for 24 years and states that this is becoming a problem in her marriage. She has had a decreased libido for the past 6 months, and more recently, is also having pain with intercourse. The last few attempts at intercourse were so painful that the patient is now avoiding all sexual intimacy. Her only surgery was a laparoscopic hysterectomy at age 29 for severe endometriosis. She takes no daily medications and drinks a glass of wine most nights. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 78/min. BMI is 23 kg/m². On pelvic examination, the vulva has scant pubic hair, and the vulvovaginal mucosa is pale, with clear vaginal discharge. The cervix and uterus are surgically absent, and the ovaries are small and nontender bilaterally. The remainder of the examination is unremarkable. Which of the following is most likely to establish the diagnosis in this patient?

Question

Quizplus · Accepted Answer

11ec25c8_d9ca_3f8c_bc81_cd5e086ec0c6_MD0003_00 This patient has 6 months of decreased sexual libido and dyspareunia (ie, pain with intercourse), which may have various medical or psychosocial etiologies. These symptoms, along with the pale vaginal mucosa (consistent with vulvovaginal atrophy), are most likely due to menopause. Most women undergo menopause around age 51 due to age-related ovarian follicle depletion and decreased estrogen levels, resulting in vasomotor symptoms (eg, hot flashes, night sweats), vulvovaginal atrophy, and amenorrhea. In general, menopause is a clinical diagnosis defined as cessation of menses for ≥12 months in women with previously regular menstrual cycles. In women with typical menopausal symptoms and cessation of menses for ≥12 months, no additional evaluation is required. However, in women without previously normal menstrual cycles (eg, prior hysterectomy, endometrial ablation), the diagnosis of menopause cannot be made clinically because vasomotor symptoms and vulvovaginal atrophy can be due to other etiologies (eg, thyroid disorder, malignancy). Therefore, these patients require an elevated serum FSH level for the diagnosis of menopause. (Choice A) Diagnostic laparoscopy is indicated in patients with dyspareunia due to suspected endometriosis (eg, dysmenorrhea, pain with defecation). This patient's dyspareunia is more likely due to vulvovaginal atrophy related to menopause. (Choice B) The Patient Health Questionnaire-9 depression screen assesses for depression, which is a common cause of decreased libido. However, depression would not explain this patient's vulvovaginal atrophy. (Choice D) Serum testosterone level does not affect menopausal status and does not correlate with sexual function in women; therefore, it is not measured in patients with menopausal symptoms or decreased libido. (Choice E) Vulvar biopsy is used to evaluate for possible vulvar cancer in patients with vulvar lesions (that may be associated with dyspareunia). This patient has no vulvar lesions. (Choice F) Wet mount microscopy is used to evaluate abnormal (eg, malodorous, bloody) vaginal discharge in patients with vaginitis, which can cause dyspareunia. This patient's clear vaginal discharge is normal. Educational objective: Menopause is a clinical diagnosis (ie, cessation of menses for ≥12 months) that usually does not require further evaluation in patients with previously normal menses and typical menopausal symptoms (eg, dyspareunia due to vulvovaginal atrophy). Diagnosis in women without previously normal menses (eg, prior hysterectomy) is confirmed by an elevated serum FSH level. References: Genitourinary syndrome of menopause. (http://www.ncbi.nlm.nih.gov/pubmed/28697291) Female sexual function at midlife and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/30401552)

A 49-Year-Old Woman Comes to the Office for Evaluation of Decreased