Post-menopausal Atrophic Vaginitis

Women’s Health Soap Note #2

Patient Information

  • Initials: E.M.
  • Age: 62
  • Gender: Female
  • Race: African-American

Subjective

Chief Complaint

E.M. presents with discomfort during sexual intercourse and light bleeding.

History of Present Illness (HPI)

E.M., a 62-year-old African-American female, reports recurring pain during sexual intercourse, which has occurred four times over the past two months. This discomfort has led her to avoid sexual activity due to embarrassment. Menopause began at age 55, later than average, and since then, she has experienced post-menopausal symptoms including vaginal dryness, hot flashes, and thinning. While estrogen replacement therapy initially alleviated her symptoms, E.M. now experiences urgency and burning during urination and urinary incontinence, which negatively impacts her quality of life. She also notes that her vagina appears paler than usual, possibly indicating post-menopausal atrophic vaginitis.

Past Medical History

  • Hospitalizations: One hospitalization for food poisoning within the past year.
  • Surgical History: Myomectomy at age 45 to remove uterine fibroids.

Family History

E.M. is married with three children. Her 30-year-old daughter was diagnosed with fibroids at age 24. Her mother had a hysterectomy at age 40, and her sister passed away from ovarian cancer at age 48. These familial medical issues are relevant to her current health concerns.

Social History

E.M. was born and raised in Mississippi and moved to Massachusetts after marriage. She works as a real estate agent and is socially active, occasionally consuming alcohol.

Allergies

No known food, environmental, or medication allergies.

Medications

  • Tramadol: 100 mg orally once daily.

Objective

Vital Signs

  • Temperature: 97.6°F
  • Blood Pressure: 134/87 mmHg
  • Respiratory Rate: 15 bpm
  • Heart Rate: 70 bpm
  • SpO2: 97%

Physical Examination

  • Constitutional: Appears well-groomed with no acute distress. Normal ambulation.
  • Psychiatric: Good insight and judgment. Mood and affect are normal; active, alert, and oriented to time, place, and person.
  • Head: Normocephalic, atraumatic.
  • Eyes: No discharge or pallor. Pupils are equal, round, and reactive to light and accommodation (PERRLA). Corneas intact, sclerae non-icteric, vision intact.
  • Ears: No lesions; external auditory canals (EACs) clear; tympanic membranes (TMs) clear with normal mobility. No hearing loss.
  • Nose: No lesions; nares patent; no sinus tenderness.
  • Oropharynx: No erythema or exudates; moist mucous membranes; tonsils not enlarged.
  • Neck: Supple with full range of motion (FROM); trachea midline; no masses. Thyroid normal.
  • Lungs: Normal respiratory effort without dyspnea; no abnormal percussion findings; breath sounds normal with good air movement.
  • Cardiovascular: Regular heart sounds (S1 and S2); no murmurs, rubs, or gallops; normal pulses throughout, including femoral and pedal. No carotid bruits.
  • Abdomen: Soft, non-distended; normal bowel sounds; no tenderness, guarding, or masses. Liver and spleen non-tender and not enlarged.
  • Musculoskeletal: Normal muscle tone and strength; no bony abnormalities; normal extremity movement.
  • Neurologic: Normal gait and station; cranial nerves intact; sensation intact throughout.
  • Skin: No rashes, ulcers, or lesions; good skin turgor.
  • Back: Normal thoracolumbar curvature; no tenderness or spasms.

Laboratory Tests

Pending biopsy, Pap smear, ultrasound, blood tests, hysteroscopy, and culture tests.

Assessment

Primary Diagnosis

  • Post-menopausal Atrophic Vaginitis (N95.2): The symptoms of pain and light bleeding during intercourse, vaginal paleness, painful urination, and urinary incontinence are indicative of post-menopausal atrophic vaginitis. This condition arises due to decreased estrogen levels causing dryness, thinning, and inflammation of the vaginal walls.

Differential Diagnoses

  • Uterine Cancer (C55): Although the patient has post-menopausal bleeding and discomfort, lab tests have not shown uterine abnormalities. The absence of watery or colored discharge makes uterine cancer less likely.
  • Abnormal Uterine Bleeding (N93.9): Hormonal imbalance due to estrogen therapy could be contributing to light bleeding. However, the patient does not exhibit heavy bleeding or abnormal uterine findings.
  • Urinary Tract Infection (UTI) (N39.0): Symptoms of urgency and burning during urination are present, but the lack of systemic symptoms like fever or blood in urine suggests a UTI is less likely.

Plan

Treatment

  1. Topical Applications: Use vaginal moisturizers and lubricants to manage symptoms of post-menopausal atrophic vaginitis.
  2. Hormone Therapy: Prescribe vaginal estrogen cream to be applied daily for 1-3 weeks, transitioning to 1-3 times per week as maintenance therapy.
  3. Kegel Exercises: Advise performing Kegel exercises—10 squeezes, three times daily—to strengthen the pelvic floor muscles and improve urinary control.

Patient Education

  1. Lifestyle Changes:
  • Wear cotton, loose-fitting clothing to enhance air circulation and reduce vaginal irritation.
  • Avoid potential irritants such as scented products and harsh soaps.
  1. Sexual Health:
  • Emphasize the importance of regular sexual activity in maintaining vaginal health. This activity helps stimulate blood flow and fluid production, which can alleviate symptoms of post-menopausal atrophic vaginitis.
  • Encourage the patient to seek medical attention for any unusual symptoms or abnormal bleeding.
  1. Medication Side Effects:
  • Educate the patient about possible side effects of hormonal treatments and the importance of monitoring any new or worsening symptoms.
  1. Follow-Up:
  • Schedule follow-up appointments every three weeks to assess treatment effectiveness and make necessary adjustments.

Rationale

Post-menopausal atrophic vaginitis results from decreased estrogen levels after menopause, leading to vaginal dryness, thinning, and discomfort. Vaginal estrogen therapy effectively restores vaginal health by improving blood flow, thickness, and elasticity of the vaginal walls. Lubricants and moisturizers further alleviate discomfort during sexual activity. Lifestyle changes, such as wearing appropriate clothing and avoiding irritants, along with pelvic floor exercises, support overall vaginal health and address urinary incontinence.

References

  • Johansen, N., Linden Hirschberg, A., & Moen, M. H. (2020). The role of testosterone in menopausal hormone treatment. Acta Obstetricia et Gynecologica Scandinavica, 99(8), 966-969.
  • Mehta, J., Kling, J. M., & Manson, J. E. (2021). Current concepts include the risks, benefits, and treatment modalities of menopausal hormone therapy. Frontiers in Endocrinology, 12, 564781.