A 63-year-old woman comes to the office due to pain during sexual intercourse. The patient had been abstinent since the death of her husband 10 years ago and attempted intercourse recently with a new partner. Although she uses lubrication, the patient has been unable to have intercourse due to severe pain on penetration. She also had several days of post-coital spotting and mild vaginal pruritus that have resolved.
Menopause was at age 57. Since then, the patient occasionally has had small amounts of thin, malodorous vaginal discharge. She does not use scented soaps, deodorants, or douches. She is worried that her inability to have intercourse might interfere with her relationship. The patient has a history of mild hypertension and takes lisinopril.
Blood pressure is 138/84 mm Hg and pulse is 82/min. Examination of the external genitalia shows scant pubic hair; pale, thin skin; and recession of the labia minora. The introitus is narrow, small, and barely permits 2 fingers to be inserted; the vaginal mucosa is pale, smooth, dry, and slightly friable.
Vaginal pH is 6. Wet mount microscopy shows a few inflammatory cells, no clue cells, and no trichomonads.
Which of the following is the best next step in management of this patient?

Question

A 63-year-old woman comes to the office due to pain during sexual intercourse.  The patient had been abstinent since the death of her husband 10 years ago and attempted intercourse recently with a new partner.  Although she uses lubrication, the patient has been unable to have intercourse due to severe pain on penetration.  She also had several days of post-coital spotting and mild vaginal pruritus that have resolved.
Menopause was at age 57.  Since then, the patient occasionally has had small amounts of thin, malodorous vaginal discharge.  She does not use scented soaps, deodorants, or douches.  She is worried that her inability to have intercourse might interfere with her relationship.  The patient has a history of mild hypertension and takes lisinopril.
Blood pressure is 138/84 mm Hg and pulse is 82/min.  Examination of the external genitalia shows scant pubic hair; pale, thin skin; and recession of the labia minora.  The introitus is narrow, small, and barely permits 2 fingers to be inserted; the vaginal mucosa is pale, smooth, dry, and slightly friable.
Vaginal pH is 6.  Wet mount microscopy shows a few inflammatory cells, no clue cells, and no trichomonads.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97da_a98c_853d_ede05bbcfe9f_MD0002_00 This patient has vulvovaginal atrophy, a sequela of hypoestrogenemia most often associated with the postmenopausal state (ie, genitourinary syndrome of menopause) but can also occur during the postpartum period and in women receiving anti-estrogen medications (eg, leuprolide). Patients often have symptoms of dyspareunia, decreased lubrication during intercourse, and vulvovaginal pruritus. Clinical features of vulvovaginal atrophy include loss of pubic hair, resorption and/or fusion of the labia minora, vaginal introitus narrowing, mucosa thinning, and loss of rugation. Changes in cervical mucus result in an increased vaginal pH (≥5), causing a relatively malodorous discharge; however, wet mount microscopy shows only epithelial cells. Treatment includes use of water-based lubricants during intercourse. In patients with moderate to severe vulvovaginal atrophy, treatment is with vaginal estrogen, which is more efficacious than systemic (eg, oral) hormonal therapy in relieving symptoms (Choice C). In addition, vaginal estrogen avoids the risk of thrombosis and endometrial and breast cancers associated with systemic hormonal therapy. (Choice A) Clobetasol is indicated in the management of vulvar lichen sclerosus, which can present with dyspareunia due to loss of vulvar architecture (eg, vaginal introitus narrowing); however, patients also typically present with vulvar pruritus and white vulvar plaques. (Choice B) Fluconazole is indicated for candida vulvovaginitis. This patient has no vulvar pruritus, clumpy white vaginal discharge, or pseudohyphae on microscopy, making this diagnosis unlikely. (Choice D) Metronidazole is indicated for treatment of trichomoniasis or bacterial vaginosis. Trichomonas vaginalis presents with a green, frothy discharge and protozoa on microscopy. Bacterial vaginosis presents with a thin, gray discharge and clue cells on microscopy. Educational objective: Vulvovaginal atrophy (genitourinary syndrome of menopause) typically presents with dyspareunia due to vaginal introitus narrowing. Treatment is with water-based lubricants and vaginal estrogen. __________ References: Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27472999) Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society. (http://www.ncbi.nlm.nih.gov/pubmed/23985562)

A 63-Year-Old Woman Comes to the Office Due to Pain