SOME GYNECOLOGICAL PROBLEMS IN THE AGEDt Gerald W. Korn, M. I have selected just three topics for this dis- However, carcinoma of the vulva and the vagina have cussion and try to give some practical tips as to the a higher incidence in the aged. management of some of the problems that fall under Where there has been a definite blood loss, it is these headings. For the purpose of this discussion, I mandatory to perform a comprehensive examination am using the age of seventy as the lower limit of of the pelvic organs. This should include (1) a care- the aged female, although, or course, many of the ful inspection of the external genitalia (2) a speculum problems that I will mention can occur in women examination (3) a bimanual examination (4) a cer- much younger than that. However, I am trying to vical and posterior vaginal wall smear (5) a curet- avoid getting into the perimenopausal era, which has tage in almost all cases (6) a biopsy of any lesions its own particular problems. suspected as being the site of the bleeding. Postmenopausal bleeding is my first large group Even where one has found an obvious vaginal, of problems and, as you are well aware, there is a urethral or cervical lesion, a curettage should be per- long list of causes of this symptom. However, in the formed where the bleeding has been of significance. aged, the number of likely causes can be reduced to Perhaps the only exclusions should be where there a small list-others being of considerable rarity. is an obvious vulval malignancy and where the upper When dealing with women in their seventies and genital tract can be palpated and visualized and seems eighties, some of the non-malignant conditions be- to be normal. come as important numerically as the malignant. When performing the curettage, it should always Atrophic or senile vaginitis, urethral caruncles, ure- be done in a fractional or differential manner with thral prolapse, ulcerations of the prolapsed cervix, a careful exploration of, first, the endocervical canal, ulcerations of the vaginal mucosa in long-standing then, the region of the internal cervical os and finally, procidentias, ulcerations of the vaginal mucosa as a the upper cavity of the uterus. From the point of result of prolonged and neglected wearing of pes- view of subsequent treatment, it is vital to know where saries and benign cervical polyps, are all commonly the malignant lesion, if it exists, lies. Endometrial seen causes of bleeding. Generally speaking, when cancer may spread downwards into the endocervix one has reached this age, carcinoma of the cervix before spreading outwards. Once in the cervix, the becomes a rare condition and certainly has a lower spread is along channels draining the cervix-that is, incidence than that of carcinoma of the endometrium. the spread is the same as in a primary cervical can- cer. Whereas the treatment of a carcinoma limited tPaper presented at the Annual Meeting of the College of Family Physicians of Canada, Saskatchewan Chapter, Sas- to the body of the uterus is either a preliminary katoon, 1968. intracavity and vaginal vault radiation using the Hey- man's technique, to be followed by surgical removal AUTHOR of the uterus, tubes and ovaries, the management of *Gerald W. Korn, M.D.; extension to the cervix is more complicated involving M.R.C.S.; L.R.C.P.; D.R.C. the same preliminary radiation and a subsequent O.G.; F.A.C.O.G.; Assistant Wertheim hysterectomy and lymphadenectomy, or Professor, Obstetrics a n d that type of major surgery without preliminary radia- Gynaecology, University of tion. Saskatchewan. Chief of De- see reason partment of Obstetrics and In point of fact, I cannot really any Gynaecology, Saskatoon City why every curettage performed at any age for diag- Hospital. nostic purposes should not be of this same fractional type. In this way, the origin of an unsuspected car- 22 CANADIAN FAMILY PHYSICIAN-DECEMBER, 1968 cinoma would always be apparent when subsequently Very often there is associated with an atrophic diagnosed histologically and this would then prevent vaginitis an atrophic urethritis. There is an eversion a number of unnecessary repeat examinations. of the urethral mucosa which pouts outwards and very Turning to some of the more common causes of often gives a picture similar to the urethral caruncle. small amounts of bleeding-first of all, atrophic The urethral mucosa may easily be damaged by rub- vaginitis, sometimes called senile vaginitis, rarely bing on underclothes and a granular and occasionally causes more than a serosanguinous discharge, but ulcerative appearance is seen. The local application to the elderly woman who suddenly finds her panties of estrogen cream within the vagina and some gently soiled or notes this blood on the toilet tissue, it can rubbed into the urethra every time the application be most distressing. Following the usual examinations is inserted, will soon improve the appearance of the and having identified the cause of the bleeding as urethra and even reverse the eversion. within the vagina, the treatment is relatively simple. The urethral caruncle, which is either a granu- I use Dienestrol Cream and I prescribe initially two lomatous or angiomatous lesion, is a polypoidal tubes with instructions to use one applicatorful each cherry-red lesion of the posterior wall of the urethra night until both tubes have been emptied. If the wom- and is usually very tender when touched. It usually an is frail and apparently unable to introduce the bleeds very easily too. If there is some doubt about medication herself, a relative, companion, V.O.N. the differential diagnosis between it and a urethral nurse or nurse in the Home Care Programme, should eversion with granulation, I use Dienestrol Cream do it for her. I like to re-examine the vagina at the for about ten days first of all and then, if the lesion end of the treatment and if, as one would expect, persists, I cauterize this in the office. If it is too tender the vagina is well estrogenized-it being pink and to cauterize, one or two cc's of 1 % Xylocaine can be rugose once more, I ask the woman to return in three introduced by a 22 gauge needle below it and it can months time for further examination, or make arrange- then be cauterized. Large caruncles usually need to ments to examine her elsewhere. In many cases, the be excised and after this is done a few fine stitches effect of the treatment will have worn off by then of 000 plain catgut on an atraumatic needle are in- and a further tube of cream will be required. I usually serted to control the bleeding from the base of the find that the use of one tube every three months is lesion. satisfactory treatment and will keep the atrophic Turning now to bleeding ulcerative lesions of the changes at bay and certainly will prevent bleeding vagina, one must suspect the existence of a carcinoma and vaginal soreness. Some people prefer the intro- of the vagina until proven otherwise where one is duction of two applicatorsful every week. as opposed faced with an ulcer of any size which bleeds to touch. to the ten or so applications every three months, and The edges of an ulcer can be biopsied using either a I would have no quarrel with that method of treat- punch biopsy or a knife biopsy, again under the same ment. I think you will all agree that it is imperative type of local anaesthetic and as an out-patient pro- that the patient be followed at regular intervals to cedure. If the ulcer is large and there is a major make sure that she is neither getting an insufficient degree of prolapse, replacement of the prolapse and amount nor an unnecessarily excessive amount of local applications of Dienestrol Cream do wonders. therapy. The patient should be given regular appoint- The healing is very rapid. Unfortunately, this may ments for follow-ups, or, if one is dealing with a mean keeping the patient in bed for long periods of Nursing Home or a bedridden patient, regular visits time with all its attending problems. When one is should be made to the patient. Sidetracking for just dealing with a severe degree of prolapse, however, one moment, atrophic vaginitis may produce a num- there is no real alternative. The advantage of replacing ber of different symptoms other than bleeding. Vagi- the prolapse and hence improving the lymphatic and nal soreness and irritation, a purulent discharge, re- venous drainage and the rapid healing therefrom, prob- current attacks of urinary frequency, urgency and ably outweighs the dangers of bed confinement. dysuria and dyspareunia, in those still full of the joys of spring, may all occur and all will benefit from the This leads me to my second topic-that of pro- use of the local cream. When the are lapse. Major degrees of prolapse, for instance the symptoms third enterocele with present, I prefer local application of the estrogen degree cystocele, rectocele, uterine prolapse or, worse still, the complete proci- rather than the systemic use of estrogen, as some of dentia, may make the later years of life one of re- the side effects such as nausea, breast soreness and lative misery. I have already mentioned the problems lower abdominal cramps, may become apparent with that ulceration may bring, with its attendant discharge oral or injectable materials but rarely do so with the of pus or pus and blood mixed. The existence of a local applications.