CHAPTER 47 GYNECOLOGIC DISORDERS
Practice of Geriatrics
CHAPTER 47 GYNECOLOGIC DISORDERS
Marsha Smith, M.D.
Age-Related Changes of the Female Reproductive System
Benign Gynecologic Disease
Malignant Gynecologic Disease
Estrogen Replacement Therapy
In every adult age group, females now outnumber males, reversing the ratio at the beginning of the twentieth century. For generations the average age at menopause has remained stable at 50 years while women’s life expectancy in the United States has increased.1 At age 65 a woman may anticipate living an additional 18 years, and a 75-year-old woman may expect to live to age 85.2 At present one third of American women are postmenopausal and will be postmenopausal for a third of their lifetime. Today 20% of the female population of the United States are aged 65 years or older; at the end of the twentieth century, 60% of the United States population aged 65 and over will be women, and they will account for 70% of a primary physician’s practice. Appropriate care for this population requires an understanding of medical problems related to aging in general and female endocrine decline in particular, a combination of both geriatric and gynecologic knowledge.
Women are more frequent utilizers of the health care system than their male counterparts.3 Of women over age 65, 88% saw a physician during the past 12 months3; 75% of women in this age group visit a physician an average of five times a year; and 85% see general internists and family practitioners rather than gynecologists for their routine gynecologic care.3
Older women commonly fail to undergo routine gynecologic examination and screening procedures, and when a gynecologic problem is diagnosed, they have been symptomatic for an average of 8.3 months and have had no pelvic examination for an average of 4.5 years.4
Only recently has there been consensus regarding recommendations for the periodic gynecologic examination of women. Medicare first began coverage for Papanicolaou (Pap) smear screening for cervical cancer in 1990.5,6 The National Cancer Institute (NCI) set a goal of 80% to 90% participation by women in triennial Pap screening by the year 2000. In 1988, NCI, American Cancer Society (ACS), American Medical Association (AMA), and American College of Obstetricians and Gynecologists (ACOG) published a consensus recommendation of triennial Pap smear screening with no age limit after two negative sequential Pap smears. An annual pelvic examination as part of a periodic health examination permits evaluation of pelvic organs for which effective screening modalities do not exist. At present, between 50% and 80% of American women aged 65 years and older have had inadequate Pap screening according to these consensus criteria.7,8
The present population of American women over age 65 may represent a unique cohort. These women were born prior to the emergence of gynecology as a recognized medical specialty, were post–reproductive age when Pap smear cytologic screening as part of an annual gynecologic examination became routine, and were postmenopausal when estrogen replacement therapy was introduced. The present cohort never established the habit of regular gynecologic care and hesitate to accept hormone replacement therapy.
The older female patient has medical problems resulting in morbidity and disabilities that negatively impact quality of life. Many of these problems have an underlying gynecologic etiology and, with appropriate attention to gynecologic history and examination, can be prevented or diagnosed and treated. Up to 30% of postmenopausal women have undiagnosed gynecologic problems.9
AGE-RELATED CHANGES OF THE FEMALE REPRODUCTIVE SYSTEM
The female endocrine system is the only endocrine system with a physiologically discernible decrease in function. This age-related change occurs at three levels: the ovarian or endocrine organ level, the estrogen or circulating hormone level, and the target organ level. Both intrapelvic and extrapelvic target organs are affected. Decreased ovarian function and decreased circulating estrogen result in short-term acute symptoms and long-term chronic disease. There is now abundant epidemiologic and clinical evidence to suggest that menopause induces specific deficiencies that can be alleviated or even prevented by appropriate estrogen replacement therapy.
Atrophic changes secondary to a decrease in circulating estrogen occur in all tissues with estrogen receptors. This change, characterized by a decrease in vascular and adipose tissue and an increase in fibrous tissue, results in smaller target organ size. A loss of follicle number and responsiveness occurs in the ovary, and the sclerotic ovary atrophies to a size of 1.5 × 1.0 × 0.5 cm on average, which is not palpable. Physiologic enlargement and functional cysts should not be present in postmenopausal ovaries.
The vagina becomes pale, shortened, and narrowed, with weakened walls. Vaginal tissues become thin, dry, and shiny, with scant discharge and decreased lubrication. Decreased glycogen deposition in the superficial vaginal epithelium results in a decrease of lactic and acetic acids, and the vaginal pH changes from acidic (3.8–4.2) to alkaline (6.5–7.5). Recognizable mucosal layers (basal, intermediate, and superficial) are lost, as demonstrated by a vaginal maturation smear. A combination of disuse and estrogen deprivation results in introital stenosis.
The vulvar skin becomes thin, and there is increased keratinization and sparse hair growth. The vulvar mucosa decreases in thickness, with atrophy of the subcutaneous fat, loss of vascularity, and decreased secretion by the vestibular glands. The uterus reverts to the cervical-to-fundal childhood ratio of 2:1 and decreases in overall size until it is no longer palpable in women over age 75. The flattened, retracted, and pale cervix is often difficult to isolate and identify, and the squamocolumnar junction recedes within the stenosing cervix. The bladder and urethral mucosa, of embryologic origin similar to that of other female genital organs, contain estrogen receptors and also undergo atrophic changes.
Estrogen-dependent tissues outside the pelvis are also affected. Estrogen receptors have been identified in the skin, which becomes thin with decreased collagen; hair follicles; and sebaceous and sweat glands, resulting in dryness and decreased resilience due to estrogen deprivation. Estrogen receptors are present in bone, and decreased estrogen availability results in a negative calcium balance and increased bone resorption. The estrogen receptor–rich breasts lose connective tissue, and adipose tissue replaces the glandular breast tissue. Decreased estrogen levels are associated with increased levels of lipoproteins, particularly cholesterol and low-density lipoproteins, and estrogen receptors have been identified in vascular endothelium. There also appears to be a direct as well as an indirect central nervous system response to decreased estrogen, resulting in insomnia, depression, and possibly some cognitive decline.
Postmenopausally there is increased peripheral conversion of androgen into estrone, a weak estrogen. Estrogen levels fall to approximately 20% of the reproductive level, and progesterone levels fall by 60%. The androgen-to-estrogen ratio shifts in favor of the androgenic steroids.
A lifetime plan of health care for women should be established prior to menopause and should anticipate these changes. Good gynecologic care of the elderly patient requires documentation of relevant medical and gynecologic history, adequate examination, and recommendation of appropriate screening.
Special problems make it difficult to obtain a gynecologic history from the older patient, further emphasizing the advantage of adequate earlier medical records. Medical records may be inaccessible and family members may not know relevant gynecologic history when an older patient is unable or unwilling to recount her history owing to cognitive decline or generational modesty. A history of complicated or uncomplicated pregnancy and delivery, prior gynecologic disease and surgery, and hormonal or radiation therapy should be sought. Prior to 1960, subtotal or supracervical hysterectomy was common, and 30% of women reporting “total hysterectomy” are found to have remaining cervical stumps.10 From 30% to 70% of women reporting “hysterectomies” have an intact cervix and/or ovaries. Many women received radium therapy for control of abnormal uterine bleeding in the early twentieth century.
Prior Pap smear screening and mammography should be recorded. Family history, particularly of endocrine-related malignancy, may be contributory. Symptoms such as dyspareunia, incontinence, bleeding, discharge, or itching may direct attention to particular gynecologic problems.
The periodic gynecologic visit should include measurements of height, weight, blood pressure, and pulse, and examination of the thyroid, breast, abdomen, pelvis, and rectum. It is often necessary to persuade the older woman of the benefit of the pelvic examination. Adjustments must be made in the approach and equipment used for a gynecologic examination. A regular examination table with stirrups can be used for the majority of patients, but the traditional lithotomy position may be uncomfortable or impossible for some patients owing to arthritis, osteoporosis, or lack of cooperation or assistance. An automated examination table facilitates positioning, and examination may be adequately performed in the left lateral decubitus or Sims position. Necessary equipment includes proper-sized specula; a narrow 1.0- to 1.5-cm bivalve Pedersen speculum; and small, medium, and large Graves specula. A clear plastic anoscope is an appropriate alternative. A 2× to 4× magnifying glass improves vulvar examination. Atrophic change and a narrowed introital opening may preclude introduction of the narrowest speculum.
The bladder must be emptied. Examination of the pelvis begins with visual examination and palpation of the external perineal and vulvar tissues with the gloved hand. Descriptive mention should be made of the appearance of the mucosal tissues and the presence and location of any lesions. Separation of the labia may reveal the presence of a urethral caruncle, a benign erythematous protrusion of the urethral mucosa through the external urethral orifice, which is usually asymptomatic and requires no treatment. Any discharge can be sampled. Since lubricating gel compromises the cellular integrity of the cytologic specimen, warm water is used to facilitate introduction of an appropriate-sized speculum.
The speculum is inserted with closed blades parallel to the vaginal opening and gently turned while keeping pressure directed toward the rectum. When the speculum is opened the cervix will be in view unless narrowing of the vagina prevents adequate insertion. Despite introital narrowing and cervical stenosis in the postmenopausal female, over 90% of older women tolerate speculum examination and Pap screening. In older women the cervix is atrophic or friable and the os is stenotic.
When the transformation zone is visible, either a moistened cotton applicator or a plastic or wooden spatula may be used to obtain the cervical sample; without a visible transformation zone, a moistened cotton applicator, glass pipette, or Cytobrush should be used. A digitally directed “blind” Pap smear can be done. A saline-moistened cotton-tipped applicator can be inserted and an adequate Pap sample obtained without cervical trauma or bleeding. In the absence of a history suggesting cervical disease or a visible lesion, a single sampling of the squamocolumnar junction is adequate. Cervical cytology should always be attempted, especially if prior sampling has been inadequate. The smear made on the microscope slide should be neither too thick nor too sparse to ensure accurate reading, and fixative should be applied immediately.
Rotate and remove the speculum slowly while viewing the entire vagina and especially the posterior wall. The vagina should be inspected for signs of atrophic vaginitis such as mucosal friability, petechiae, telangiectasia, and vaginal erosions. A cytologic maturation index showing 100% parabasal cells confirms atrophy, although not necessarily atrophic vaginitis.
Bimanual examination is adapted to the adequacy of the introitus. The uterus should be small, and the ovaries should not be palpable. The visible or palpable presence or absence of the cervix is recorded. Pelvic muscle laxity may cause a cystocele, enterocele, rectocele, or uterine prolapse. Using the examiner’s finger that is inserted in the vagina, a single speculum blade, or a tongue blade, the physician should apply support sequentially to the anterior and posterior vaginal walls and ask the patient to cough or strain. Bulging of the anterior wall when the posterior wall is stabilized indicates a cystocele. Conversely, bulging of the posterior wall indicates a rectocele and/or enterocele. Rectovaginal examination permits evaluation of the thickness and condition of the rectovaginal septum, the presence of disease, and assessment of the culde-sac. Rectal examination is often the only means of assessing the pelvic organs. Stool should be tested for occult blood. Assessment for incontinence, bladder capacity, and post-void residual quantity may be done if indicated.
An integral part of adequate gynecologic care is careful discussion of the examination findings, recommendations for therapy, referral for specialized evaluation, and scheduling for follow-up and periodic examinations and screening procedures with the patient and involved family members.
BENIGN GYNECOLOGIC DISEASE
Eighty percent of gynecologic problems in women over 60 years of age are related to postmenopausal bleeding, vulvovaginal inflammations or infections, genital prolapse, or alterations in bladder function. Common gynecologic problems in older women include:
Relaxation of pelvic structures
Inflammation and infection
Atrophic changes occur during menopause in all tissues with estrogen receptors. Loss of rugae, thinning, pallor, and loss of elasticity are the common atrophic changes in the vaginal mucosa of aging women. Vulvar changes become apparent months or years after vaginal atrophy is first observed. The labia minora shrink in thickness and length and may be difficult to identify. The introitus may become narrow and rigid so that intercourse is painful or impossible. Decreased maturation of vaginal mucosal epithelium can lead to atrophic vaginitis with symptoms of burning, itching, bleeding, leukorrhea, and dyspareunia. Locally applied conjugated vaginal estrogen cream in a standard dose of 0.625 mg/g (1 to 4 g daily) is systemically absorbed. Lower doses of topical estrogen, 0.5 mg every third day, may provide relief with fewer systemic effects. Alternative regimens include 0.3 mg vaginal estrogen daily for 3 months, combined with periodic progesterone; a water-based lubricant; and dilute acetic or boric acid douches to restore an acidic vaginal pH. Estrogen deprivation can result in atrophy of bladder and urethral tissue, producing dysuria, urinary frequency, urgency, and incontinence. These symptoms also respond well to low-dose systemic and vaginal estrogen therapy. Restoration of genitourinary tissue function usually requires months of treatment.
Inflammations or Infections
An increased incidence of infection and vaginitis in older women is related to the higher vaginal pH and decreased structural resistance to infectious agents. The bacterial and fungal causes of vaginitis are similar to those in younger women and the evaluation and management are also essentially the same. Topical estrogen treatment alone or in combination with antibacterial or antifungal creams will reestablish a more resistant vaginal epithelium. Trichomoniasis is uncommon in postmenopausal patients, but monilial vulvovaginitis is more frequent, especially in the diabetic patient or one recently treated with antibiotics. Ascending pelvic infections and abscess formation are rare. Vulvovaginitis, simultaneous involvement of both vaginal and external vulvar tissues, is common, and combined therapy is most effective. Any dermatologic condition, such as psoriasis or seborrheic and contact dermatitis, may involve the vulva.
Eighty percent of postmenopausal vaginal bleeding has a benign cause. Evaluation requires pelvic examination with Pap screening and endometrial sampling. Endometrial atrophy is found in 70% of these cases, endometrial hyperplasia in 15%, polyps in about 9%, and uterine sarcoma or other lesions in about 1% of cases.11
Relaxation of Pelvic Structures
The endopelvic fascia, uterosacral and cardinal ligaments, and levator ani muscles, which support the pelvic organs, become weakened owing to obstetric trauma, obesity, strenuous activity, and atrophic change, resulting in relaxation of pelvic structures. Uterine prolapse is described according to the degree of descent of the uterus. The cervix presents at the introitus in first-degree prolapse, the cervix and half of the uterus protrude through the introitus with second-degree prolapse, and the entire uterus is exposed and the vaginal walls everted in third-degree prolapse or procidentia. Symptoms of prolapse are a sensation of pelvic heaviness or vaginal mass, back pain, urinary incontinence, or bleeding of the exposed mucosal tissues. Mild relaxation may be treated with Kegel exercises to increase the muscle tone of the pelvic floor.
Vaginal surgery is the usual therapy for complete uterine prolapse, but when surgery is medically contraindicated a trial of a pessary for support is practical. A ring or doughnut pessary treats prolapse by applying pressure in all directions on the vaginal wall and lifting the uterus into the pelvis and holding it there. Inflatable pessaries are easier to insert and remove. After insertion of a pessary, the patient must be reexamined within 24 hours to assess proper placement and effectiveness and to rule out discomfort or urinary obstruction or retention. Mucosal tissues may be protected by intermittent vaginal application of estrogen cream. Pessary care includes periodic removal and cleansing, pelvic examination, and replacement with a new pessary as needed.
Cystocele or prolapse of the bladder commonly accompanies or precedes uterine prolapse. Symptoms include a sensation of vaginal fullness or a palpable mass protruding from the vagina. Recurrent cystitis due to incomplete bladder emptying, urinary incontinence, or vaginal ulceration due to exposed mucosal tissues may necessitate surgical repair. Urethrocele or eversion of the urethral mucosa with inflammation or bleeding may occur at the same time as the cystocele. Symptomatic urethroceles may benefit from topical application of estrogen. A large rectocele or bulging of the posterior wall of the vagina may result in incomplete stool evacuation.
There is an increased incidence of urinary tract infection in older women due to increased vulnerability of atrophic tissues to bacterial invasion and to an increase in residual urine after voiding. Symptoms include frequency and pain or burning with urination. When recurrent urethritis occurs without a dominant causative organism, local estrogen therapy may be helpful.
Women over age 65 commonly suffer incontinence (see Chapter 18). Incontinence may exist without a cystocele; likewise, pelvic floor muscle laxity, even when present, may not be the cause of incontinence. Stress incontinence is best assessed with a provocative stress test. With a full bladder, the standing patient provides a single, vigorous cough. The patient is monitored for urine leakage. A false-negative result may occur if the patient does not relax, if the bladder is not full, if the cough is not strong, or if the test is conducted in the upright position in a woman with a large cystocele. In the last case, the test should be repeated in the supine position with the cystocele reduced. Urethrovesical pressure dynamic studies indicate that the mechanism of continence in significant uterovaginal prolapse is urethral obstruction.
Doughnut pessaries used to replace the prolapse may cause the previously continent patient to become incontinent. The doughnut replaces a prolapsed uterus but gives no support to the proximal urethra. Lever pessaries applied behind the public arch support the proximal urethra. Smith and Hodge–type pessaries promote increases in the functional length and closing pressure of the urethra without causing obstruction. Pessaries may be used as temporizing measures prior to surgical vaginal repair or as definitive treatment when surgery is contraindicated. The aged, the frail, and the disabled are unfortunately also those most likely to develop complications from pessary use, such as embedment, incarceration, and, rarely, fistulae from poorly fitted, infrequently monitored, or forgotten pessaries.
MALIGNANT GYNECOLOGIC DISEASE
At the 1995 American Cancer Society National Conference on Gynecologic Cancers significant progress was noted in overall diagnosis and treatment during the past 25 years; however, there was a relative lack of progress for older patients.12 The incidence of all gynecologic cancers increases with increasing age.4,13 Twenty-seven percent of cervical cancer, 45% of endometrial cancer, and 43% of ovarian cancer occur over age 65.13 Forty-four percent of breast cancer,14 65% of vulvar cancer,13 and 57% of vaginal cancer13 also occur in this age group.
The most common gynecologic malignancies in older women are similar to those in the general population. Cancer of the corpus uteri is the most common,15 with cancers of the ovary and cervix following second and third, respectively. Surveillance, Epidemiology, and End Results (SEER) data show that 81% of gynecologic cancers in elderly women originate in the uterine corpus or ovary, making these two malignancies by far the most common gynecologic malignancies for this age group.4,13 The risk of a woman over age 65 developing ovarian, endometrial, or cervical cancer compared with women aged 40 to 65 is nearly three times as high for ovarian cancer, nearly twice as high for uterine cancer, and 10% higher for cervical cancer.16
Diagnosis of gynecologic cancer in the elderly occurs at a more advanced stage. Early-stage ovarian cancer has few symptoms and is very difficult to diagnose, so the majority of patients present with advanced-stage disease. At present the bimanual pelvic examination remains the most cost-effective means of diagnosis, but it is not sensitive enough for the detection of early disease. Two diagnostic modalities are under active investigation: tumor marker CA-125 and sonography.11 Annual endometrial sampling or transvaginal ultrasound for screening asymptomatic women for endometrial cancer is not cost-effective either, although it may identify women at increased risk.11,17
Cervical cytology (Pap smear) screening, introduced over 50 years ago, is effective in detecting preinvasive disease and has resulted in a dramatic decrease in the incidence and mortality of invasive cervical cancer. Owing to regular pelvic examinations with Pap screening, there has been a 70% decrease in age-adjusted cancer death rates for carcinoma of the cervix in the last 30 years. The Pap smear false-negative rate of 20% may be higher in elderly women because of the difficulty encountered in adequately sampling the squamo-columnar junction within the endocervical canal. Forty percent of elderly women in this country have never had a Pap smear,18 and older women who have Pap smear screening have two to three times the number of abnormal smears.18 Because of the cervix’s unique accessibility, 90% of cervical cancer can and should be detected early with a Pap smear.
Carcinoma of the endometrium is the most common gynecologic cancer in elderly women. About 45% of cases are diagnosed over age 65, and 36% over age 75. Adenocarcinoma of the endometrium occurs along a continuum from cystic hyperplasia to adenomatous hyperplasia to atypia to early carcinoma to frank carcinoma. Adenomatous hyperplasia is known to antedate adenocarcinoma in 25% to 30% of cases. Women at risk include those with a family history of genital cancer and those exhibiting the characteristics of Saint’s triad of obesity, hypertension, and diabetes mellitus. Other associations are persistent anovulatory bleeding, chronic liver disease, pelvic irradiation for benign conditions, nulliparity, and late menopause.
The initial symptom, postmenopausal bleeding, occurs early in the spectrum of the disease. Almost all have abnormal vaginal bleeding—serosanguineous to frank bleeding—with pyometra and hematometra if a stenosed cervical canal obstructs uterine drainage. Up to 50% of endometrial carcinoma is picked up on Pap screening. Pain occurs late with advanced disease. Diagnosis is made by endometrial sampling and dilation and curettage (D&C), and endocervical curettage is performed to determine tumor extent. From 85% to 90% of cases will still be confined to the uterus at the time of diagnosis. Prognosis is encouraging because of early diagnosis and precise treatment selection. Although accounting for 50% of all new female genital cancer, endometrial carcinoma is responsible for only 23% of gynecologic cancer deaths because its diagnosis is usually made early. The age-adjusted death rate has decreased 50% over the past 30 years.
The etiologic role of estrogen in the development of adenocarcinoma of the endometrium is established. While the source of estrogen may be polycystic ovarian disease or hormone-producing ovarian tumors (granulosa cell/thecoma), the most common source in postmenopausal women is unopposed exogenous estrogen. An increased incidence of endometrial adenocarcinoma was noted in the early 1970s among women receiving estrogen replacement therapy. We now recognize that unopposed estrogen replacement therapy increases the risk of endometrial cancer by two to ten times, the increase in risk directly related to dosage and duration of therapy and continuing for up to 10 years after discontinuation.19 Lower estrogen dosage and the addition of cyclic progestogens significantly reduce this risk. Progestational agents reverse adenomatous hyperplasia and carcinoma in situ and may also be used in advanced disease to control vaginal bleeding and decrease metastasis. Estrogen replacement therapy has been prescribed without increasing the recurrence rate after treatment of Stage I adenocarcinoma of the endometrium.17,20
The incidence of all cervical cancers increases up to the last decade of life15; the increased incidence in older women reflects diagnosis in symptomatic women rather than screening in asymptomatic women. About 27% of cases of carcinoma of the cervix occur after the age of 65 years; 25% of new diagnoses of invasive cervical cancer are made in women over age 65 years, and of these, 65% had never had Pap smear screening.21 Only 37% of women over age 65 had a Pap smear within 12 months,10 and slightly more than 50% of women aged 65 and older have had a Pap smear within the past 3 years.5
Ninety-five percent of cervical carcinoma is of squamous cell type arising in the transformation zone. Similar to endometrial carcinoma, squamous cell carcinoma develops along a spectrum from cervical dysplasia to in situ to invasive disease. Forty percent progress from carcinoma in situ to invasive carcinoma within 1 to 20 years (average, 10 years). It is not known if the conversion rate increases with age. Women at highest risk have included those younger than age 18 at first coitus, those with multiple sex partners or a partner with multiple partners, smokers, and those with a history of sexually transmitted disease, particularly human papillomavirus or herpes simplex.
Early disease is asymptomatic; the first sign is commonly an abnormal Pap smear. There may be vaginal spotting, usually postcoital, or discharge with early invasion; pain rarely occurs until spread to the vagina or secondary infection occurs. Frequency, urgency, rectal tenesmus, or rectal bleeding are late manifestations. Low back pain and leg pain result from compression of lumbosacral nerves.
Carcinoma of the cervix is the only gynecologic cancer preventable by screening. The frequency of screening and the age at which to discontinue screening are subjects of controversy. Following two negative smears there is low risk for at least 5 years, while screening every three years between the ages of 25 and 64 provides 95% maximal protection. There have been no prospective trials of cervical cancer screening examination in the elderly, but Pap smear sensitivity is unaltered by age. False-positives may be due to atrophic change. Before age 65 an abnormal smear indicates invasive cervical cancer in 1 of 30 positive smears; after age 65 this rate increases to 1 of 5.21 Five-year survival for Stage I cervical carcinoma treated with surgery or irradiation is 85% to 90%; there is no difference in survival by stage among older women. From 1973–1974 to 1986–1987, mortality from carcinoma of the cervix decreased 17% in women over age 50 and decreased 43% in women under age 50.
Ovarian carcinoma accounts for 52% of all gynecologic cancer deaths, and the age-adjusted death rate has remained stable for the past 30 years.22,23 Fifty percent of cases are diagnosed after age 65 and 12% after 75 years of age.11 Three distinct hereditary patterns have been described: ovarian cancer alone, ovarian and breast cancers, and ovarian and colon cancers. However, 90% to 95% of ovarian cancer is of sporadic occurrence. Signs and symptoms are vague gastrointestinal discomfort and abdominal swelling, pelvic pressure, mild constipation, abdominal mass, weakness, and weight loss.
Ovarian cancer should be suspected in 40- to 69-year-old women with persistent undiagnosed gastrointestinal symptoms. Often asymptomatic in the early stages, most patients have widespread disease at the time of diagnosis. About 75% of cases are diagnosed late10,24; 75% present with an abdominal mass and 50% with ascites. The annual pelvic examination of asymptomatic women yields one early ovarian carcinoma per 10,000 routine pelvic examinations. A finding of adenocarcinoma cells on Pap screening, with negative evaluation of vulva, vagina, cervix, and endometrium, indicates ovarian, tubal, or other intra-abdominal carcinoma. Routine ultrasound is helpful in the obese or uncooperative patient.
Postmenopausal palpable ovarian syndrome (PPOS) is a term applied to palpable ovaries on bimanual pelvic examination of postmenopausal women, especially after the age of 70 years. The high risk of malignancy in this age group requires immediate investigation; however, only 10% of patients with PPOS subjected to oophorectomy may have malignant ovarian neoplasm.25 It has been recommended that all perimenopausal women have bilateral oophorectomy at the time of pelvic surgery for benign disease. The five-year survival rate for ovarian carcinoma is 25% and has been unchanged for decades. The death rate increases with age, with peak mortality occurring at ages 80 to 84 years.
Vulvar dystrophies as well as vulvar neoplasia increase in frequency with advancing age. Any woman with perineal complaints should undergo careful inspection of the vulva, followed by a biopsy of any suspicious lesion. Until histologically proven otherwise, all vulvar lesions must be suspected of being malignant. Lesions may be pigmented or white and vary in appearance depending on local factors such as excoriation and hygiene. White lesions were previously called “leukoplakia,” erroneously implying premalignant or malignant disease; the whiteness, however, indicates hyperkeratotic skin with loss of skin pigment and decreased vascularity. Atypia occurs in only 5%; nevertheless, all should be biopsied. All dark lesions must be excised to detect atypia and melanoma.
At the time of presentation, approximately 3% to 5% of women with vulvar lesions have invasive carcinoma. A 1% aqueous solution of toluidine blue dye fixes to cell nuclei. A 1% aqueous acetic acid solution applied 3 minutes after the dye decolorizes unbound dye. Since there are no surface nuclei on normal vulva, no blue stain remains on normal skin surface. Nuclei may be present, however, in both benign and malignant lesions. Toluidine blue–directed biopsies may be done following local infiltration of 1% lidocaine, using a Keyes dermal punch or disposable Baker’s biopsy punch. Local hemostasis is achieved with silver nitrate.