A 57-year-old woman comes to the office for evaluation of vaginal pruritus, pain with urination, and increased urinary frequency. The patient's symptoms have been present for several months but have intensified recently. Her husband passed away 4 years ago, and the patient had not been sexually active until 6 months ago with a new partner. She has had some pain with intercourse and has tried over-the-counter, water-based lubricants with little relief. Her last menstrual period was 7 years ago. She has poorly controlled type 2 diabetes mellitus with a recent hemoglobin A1c of 8.4%. BMI is 28 kg/m². Vital signs are normal. Pelvic examination shows thin vulvar skin with reduced elasticity. The vagina appears pale, dry, and has multiple areas of petechiae. There is minimal clear discharge in the vault. Vaginal pH is 6.5. Urinalysis is normal. Which of the following is the best next step in management of this patient?

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11ec25c8_d9c8_6ac9_bc81_1b5c19310c5a_MD0003_00 This patient has genitourinary syndrome of menopause (or atrophic vaginitis), in which reduced estrogen levels associated with menopause cause decreased blood flow and reduced collagen and glycogen content in vulvovaginal tissues. This results in thin vulvar skin with reduced elasticity and loss of vaginal tissue pliability that cause vaginal pruritus and dyspareunia. Due to the proximity of the bladder to the vaginal epithelium, the bladder trigone and urethral epithelium may also atrophy, resulting in dysuria and urinary frequency (mimicking a urinary tract infection). Patients typically have a pale, dry vagina with petechiae (due to easily denuded epithelium) and minimal vaginal discharge with a pH >4.5 (due to decreased lactic acid production from low glycogen content). The first-line management of atrophic vaginitis is vaginal moisturizers and lubricants. In patients with no symptom improvement, treatment is with vaginal estrogen (eg, cream, tablet, ring), which increases blood flow and glycogen content to the vulvovaginal tissues. (Choice A) Metronidazole treats trichomoniasis and bacterial vaginosis, which are associated with an increased vaginal pH (ie, >4.5 pH). Patients with trichomoniasis may have cervical petechiae or punctate hemorrhages, but usually also have a copious, frothy green discharge (not seen in this patient). Patients with bacterial vaginosis typically have a malodorous, thin vaginal discharge with no other symptoms (eg, pruritus), making this diagnosis unlikely. (Choice B) Patients with urinary tract infections are typically treated with oral nitrofurantoin. Although this patient has dysuria and urinary frequency, her urinalysis is normal, making a urinary tract infection unlikely. (Choice C) Topical corticosteroid cream is used for vulvar lichen sclerosus, which can present as vulvar pruritus and dyspareunia. However, patients have thin, white skin that forms into plaques, destroying the normal vulvar architecture. In addition, lichen sclerosus does not affect the vagina, making this diagnosis unlikely. lichen sclerosus (Choice D) Topical nystatin treats candida intertrigo, which can present with vulvar pruritis, particularly in patients with poorly controlled diabetes mellitus. However, candida intertrigo typically presents with erythematous plaques with satellite lesions involving the inguinal folds (not seen in this patient). Educational objective: Patients with the genitourinary syndrome of menopause (ie, atrophic vaginitis) can have vaginal pruritis, dyspareunia, thin vulvar skin with decreased elasticity, and a pale, dry vagina. First-line treatment is vaginal lubricants and moisturizers; those with no symptom improvement are treated with vaginal estrogen. References: Genitourinary syndrome of menopause: management strategies for the clinician. (http://www.ncbi.nlm.nih.gov/pubmed/29202940) Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? (http://www.ncbi.nlm.nih.gov/pubmed/26707589) Hormone therapy and other treatments for symptoms of menopause. (http://www.ncbi.nlm.nih.gov/pubmed/27929271)

A 57-Year-Old Woman Comes to the Office for Evaluation of Vaginal