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Geriatric Gynecology
Geriatric Gynecology MARY DEWITT PETTIT, M.D., F.A.C.S.* CATHERINE B. HESS, M.D.** JANE MARSHALL LEIBFRIED, M.D.t
THE purpose of this article is to emphasize the gynecologic problems peculiar to the aging groups as opposed to those women who are premenopausal. It is obvious that the aging process comes at a markedly varying rate in different persons. Chronologic age is not always a fair index of the state of the patient's tissues and recuperative powers. As people in general become older, there will of necessity be increased hypertensive and cardiovascular renal disease; increased arteriosclerotic changes in cerebral, coronary and peripheral vessels; increased incidence of diabetes mellitus and of other degenerative processes, including the development of malignancy. In the woman, to these various processes must be added the very definite effects on tissue of estrogen deprivation. Attenuation of muscular and ligamentous structures occurs during the aging process. When estrogen deprivation is added, we find defects in supportive structures becoming much more obvious. These changes can also be important in the younger woman who has for some reason been deprived of her ovarian From the Department of Gynecology, Woman's Medical College of Pennsylvania, Philadelphia.
* Professor of Gynecology, Woman's Medical College of Pennsylvania; Chief of Gynecology, Hospital of the Woman's Medical College; Visiting Chief of Obstetrics and Gynecology, Philadelphia General Hospital,' Area Consultant in Gynecology, Veterans Administration, Philadelphia.
** Clinical Associate Professor in Gynecology, and Clinical Assistant Professor in Obstetrics, Woman's Medical College of Pennsylvania; Assistant Attending Physician in Obstetrics and Gynecology, Philadelphia General Hospital; Attending Physician in Gynecology and Obstetrics, Hospital of the Woman's Medical College, Philadelphia.
t Clinical Associate Professor in Obstetrics and Gynecology, Woman's Medical College of Pennsylvania; Assistant Attending Physician in Obstetrics and Gynecology, Philadelphia General Hospital; Attending Physician in Gynecology and obstetrics, Hospital of Woman's Medical College; Attending Gynecologist, U. S. Veterans Hospital, Philadelphia. 1627
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function at a relatively early age. Roentgenograms will often show marked osteoporosis in these women, explaining various joint and muscle symptoms. When major surgical problems exist in the geriatric woman, the importance of proper preoperative evaluation and supportive treatment, as well as proper anesthesia and postoperative care, cannot be overemphasized. Age in itself is no contraindication to necessary surgery. The presence of nutritional difficulty, usually over a long period, must be recognized. The presence of hypochlorhydria and achlorhydria frequently results in poor gastric absorption. This in turn results in chronic anemia, chronic hypoproteinemia and vitamin deficiency. To insure proper wound healing, these fundamental considerations must be adequately understood and remedied. GYNECOLOGIC EXAMINATION
Evaluation of the thyroid gland is part of a gynecologic examination in any age group. The presence of solitary nodules in the gland is a danger signal, and surgical excision should in most cases be seriously contemplated. Hypofunction and hyperfunction should be evaluated and treated according to the patient's needs. Thorough examination of the breasts should precede every pelvic examination. In women who are still having some estrogenic function, cystic changes and other benign situations may well be encountered. These usually disappear after the patient's menstrual function has ceased. When her tissues show definite signs of atrophy, any mass which appears in the breast should be treated as carcinoma until it is proved to be otherwise. History of nipple discharge should be elicited. Adequate exposure of the breasts, with removal of sufficient clothing and a good light, is important in evaluating skin changes in the nipple area. The patient should be examined in both the sitting and the recumbent positions. Again, sufficient time must be taken to examine the breasts with the patient's arms elevated and at her side and with the pectoral muscles relaxed, so that skin retraction and other evidence of deep tumors may be picked up. It is unfortunate that a number of elderly women will hide known masses for many months. Some of these tumors, however, may be of the slow-growing variety, and it is not too late to offer at least palliative help by surgery. The nursing problem and discomfort due to an ulcerating, sloughing mass can usually be prevented by simple mastectomy. It will be necessary to individualize each patient according to her medical status, as to the advisability of radical surgery versus simple mastectomy and high voltage x-ray therapy. Careful abdominal expmination is of necessity the next step before examination of the pelvic organs as such. The patient who is older must be placed in as comfortable a position as possible in order to favor relaxation of the abdominal musculature. Many of these women are arthritic
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and have rigid deformities of their cervical spines. The placing of a suitable small pillow or folded towel at the base of the patient's head will help her to cooperate. Similarly, adjustment of the stirrups should be made to permit patients with arthritis of the lower extremities to be comfortable in the lithotomy position. The abdomen should be examined for previous scars, for hernia and for unusual masses and enlarged organs. If the abdomen is distended, is the distention due to fluid or gas in the intestines? Observation should be made of enlargement of the liver, presence or absence of omental "cake," the consistency and degree of encapsulation of varying masses. Many of these older people have such relaxed abdominal muscles that palpation of the organs is relatively easy. Ventral hernia and inguinal and femoral hernia are frequently found in these aging persons. The presence or absence of inguinal adenopathy should be ascertained. Pelvic Examination
For accurate evaluation of any gynecologic patient the removal of sufficient clothing, the emptying of bladder and bowel, and the placement of the patient in a suitable position are mandatory. The lithotomy position is most generally acceptable. The occasional use of the knee-chest or the Sims' position will make the visualization much easier of some lesions such as fistulas high in the anterior vaginal vault. Assorted specula of suitable length and width are easily obtainable. An adequate source of light, which can be adjusted to the individual situation, is a must. The Vulva and Vagina. The diseases of the vulvar skin and vaginal mucosa are many. Probably one of the most frequent complaints which bring an older patient to a gynecologist is vaginal discharge of some type, plus or minus itching or burning. We all have had the experience of seeing an obese patient with reddening and edema of the external genitalia and purulent, irritating discharge, a typical Candidiasis, prove to be diabetic. For completeness and brevity we shall divide the diseases of the vulva and vagina into four classes: INFLAMMATORY DISEASES. All vulvar and vaginal tissues which are daprived of estrogen are prone to trauma and infection. These tissues have poor recuperative powers. It is important to identify the predominant infectious organism in the secretions. Two simple office procedures will eliminate the presence of Trichomonas vaginitis and Candidiasis. The use of a saline suspension of secretions will show the actively motile trichomonads under the dry high power of the microscope. Ten per cent potassium hydroxide solution, one drop added to one drop of the previous saline suspension, will show up the mycelia in Candidiasis. It is most important to supply estrogen locally and sometimes orally to give the tissues recuperative power to combat the infestation. It is also important not to overtreat with any chemicals. Estrogen creme or vaginal supposi-
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tories will improve the mucosa and acidify the secretions. If patients fail to respond to this alone, specific chemotherapy may then be used. Some patients will have a nonspecific infection, which usually responds to estrogenic therapy alone. If elderly women are receiving large doses of antibiotics for any reason, the danger of yeast infestation in the vagina must be constantly kept in mind. Suitable supplements of vitamins B, C and E in the diet are helpful in prevention. Periodic check-up every three to four months may prevent annoying exacerbations. Most douches are drying and mechanically irritating and should usually be avoided in the geri,atric group. Pediculosis, scabies, fungous infection, allergic dermatoses, psoriasis, lichen planus and other dermatologic conditions present their own specific problems. Urinalysis followed by blood sugar determination and glucose tolerance test when indicated must be thought of when diabetes mellitus is a possibility. Anemia and leukemia can be ruled out by blood count. LEUKOPLAKIC VULVITIS AND KRAUROSIS VULVAE. Leukoplakia of the vulva with thickening of the skin and fissuring is considered to be a definitely precancerous lesion. The thinned and atrophic dermis will seldom undergo malignant degeneration and can be safely built up with estrogenic therapy. When in doubt, a biopsy can be easily and safely performed. The serious lesions usually produce severe pruritus and burning, and the patient will seek relief of these symptoms. If true leukoplakia exists, vulvectomy should be considered. Patients will have complete relief of itching from excision of the affected skin. There is some likelihood of recurrence of the process in adjacent areas, so that follow-up is necessary. Alcohol and other injected materials are not advised in this group because of the danger of malignancy. Large doses of vitamin A and judicious use of estrogenic hormone will help prevent recurrence. The presence of neurogenic dermatitis with the "itch scratch" cycle often complicates both the hypertrophic and atrophic situations. At times the patient may complain bitterly of itching and burning when no skin lesions are obvious. Reassurance about cancer, emollient medication, sedation, bed rest and even hospitalization may be needed to break into this sort of cycle. Many women with atrophic changes will complain of severe dyspareunia. The propl?r use of lubricants with coitus and the supplementary use of estrogens locally and by mouth will be most helpful. It may even be necessary to do a minor plastic operation to enlarge the introitus in certain patients. BENIGN CYSTS AND NEOP'LASTIC DISEASE. Elderly women may suffer infection in sebac.eous cysts necessitating antibiotics, incision and drainage. New inclusion cysts and cysts of Bartholin's glands rarely occur for the first time in the older age group. Carcinoma (adenocarcinoma) of Bartholin's gland can occur, but is rare.
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Any nodule appearing on the vulva in older women should be examined carefully in a good light. Virus warts, senile keratosis and nevi can be recognized as such. Melanoma is a dangerous lesiop. and may occur in this area. Hydradenoma is rare."The most usual malignant lesion is squamous cell carcinoma. Rarely a basal cell epithelioma may be found. These epitheliomatous lesions usually appear raised, will have rolled edges, and are firm to touch in comparison to surrounding tissue. At first they may be insensitive, but later, as they enlarge, they cause itching and burning. As ulceration develops, secondary infection will cause pain. This is frequently the time when the patient first seeks assistance. In the study conducted by the Philadelphia Committee on Delay in Diagnosis of Pelvic Cancer, physician delay in vulvar cancer cases averaged nineteen months. Patient delay is an even greater factor, since patients tend to try all sorts of home remedies before asking for medical help. It should be assumed that about 50 per cent of cases of vulvar epithelioma with ulceration will have extension to inguinal nodes. The most successful treatment is wide surgical excision of the vulva and bilateral inguinal n.ode dissection. This may be done in two or three stages in poor operative risks. Symptomatic relief in the very elderly may be obtained by simple vulvectomy alone. High voltage x-ray therapy may have palliative value, but is rarely curative. Local radium or radon application is most unsatisfactory. Biopsy of suspicious lesions should be by excision rather than incision. With prompt and adequate surgery, when inguinal nodes are not yet involved, 80 per cent five year survival may be expected. When the nodes are involved, the survival rate drops to about 30 per cent. Vaginal carcinoma is usually secondary to cervix, corpus or vulvar lesions. When this diagnosis is suspected, careful search must be made for a primary site of origin. The posterior fornix is the most likely site in the rare primary tumor. Treatment is by radical surgery if possible, but may of necessity be confined to palliative irradiation. STRUCTURAL DEFECTS. Many patients will be certain that a true neoplasm exists, and on examination will prove to have prolapsus of the uterus, plus cystocele, enterocele and rectocele. The original injury which laid the groundwork for these lesions usually occurred as a result of childbirth many years before. The typical history will often be given of a severe upper respiratory infection with prolonged cough; with unusual physical exercise, lifting, straining, and the like. Suddenly the structura.1 defect appears, and the patient is sure she has a tumor. Associated dysfunction of the urinary tract and of the gastrointestinal tract plus pain and discomfort are frequent acompaniments of this type of lesion. In the past it was customary to fit these old ladies with a pessary and stop at that. With the advent of modern anesthesia, the use of early ambulation, the use of sufficient blood replacement and careful preopera-
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M. D. Pettit, C. B. Hess, J. M. Leibfried
tive medical evaluation, it is now possible to give more permanent relief to these patients. The choice of procedure will of course be determined by the life expectancy and by the expectancy of physical activity of the patient. It is exceedingly important in the geriatric group to maintain physical activity as long as the patient can manage this. The sense of being able to help in the household and of being able to get around and lead a reasonably active life is what makes life worth living for many of these people. A pessary must be cleansed frequently and does not always prevent progression of the condition. If it is felt that the patient will live long enough and she plans to continue to be active while wearing her pessary, the cystocele and prolapsus will usually increase in intensity. The time may come when proper fitting with a pessary is no longer practicable. By that time it may be tdo late for hope of good result from surgery. Each patient should be evaluated on her own merits in that regard. For the elderly woman who is not going to be active, climb stairs, and so on, and who is past the likelihood of sexual activity, the LeFort operation, or colpocleisis, is a satisfactory operation. This may be done on poor operative risks, using procaine local infiltration anesthesia. Dilatation and curettage should always precede the repair. The only difficulty in performing this procedure will come if the patient cannot keep her legs apart and in the stirrups for a sufficient length of time. Usually the use of morphine and atropine, or other suitable narcotic adjuvant, will make this procedure possible even in a poor medical risk. ,JThe Manchester-Fothergill operation does not invade the peritoneal cavity and will give satisfactory results with associated repair of other lacerations in properly chosen cases. This must, of course, be preceded by a diagnostic curettage. Most people feel that vaginal hysterectomy is a satisfactory method of handling the severe procidentia group. Elderly patients appear to tolerate the vaginal approach better than the abdominal one. In cases of severe and recurrent enterocele it may be necessary to combine the vaginal and abdominal approach. This lesion is the one most apt to recur after any repair operation. Postmenopausal bloody discharge is a frequent complaint bringing the patient to a gynecologist. The necessity then arises for determining the site of origin of the bleeding. Because of the fragility of elderly tissues it is possible that local trauma, particularly scratching or improper douching, may cause bleeding from the vulvar and perineal surfaces. The presence of an ulcerated neoplasm on the vulva or adjacent structures may be responsible. Urethral caruncle and ectropion are frequent sources of spotting in this age group. An intravesical lesion, either polyp or neoplasm, may be responsible. A decubitus ulcer on a prolapsed cervix may cause bloody discharge on the clothing. Carcinoma of the cervix must be ruled out. Digital and speculum examination of the rectum will rule out hemorrhoids, fissures and local neoplastic growths. Many of these patients will
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show an obvious reason for the bleeding in one of these sites. It must be remembered that carcinoma of the endometrium is the most statistically likely neoplasm in the geriatric group. Because elderly cervices are apt to be stenotic, the passage of both foul and bloody discharge is likely to be periodic. It is necessary to build up a certain pressure in the cavity of the uterus before the discharge is expressed with a gush. Diagnostic curettage is the only safe method of eliminating this possibility. The Cervix. Diseases of the cervix must be ruled out in elderly patients complaining of abnormal discharge. However, owing to marked atrophic changes coming after estrogen deprivation, the cervix is usually a tiny, button-like organ. Polyps are frequently found and are usually benign. It is unusual to find the inflammatory and eroded cervices seen in younger women. The statistics on the incidence of cervical malignancy by age are as follows: Aged Aged Aged Aged
40-49 50--59 60-69 70-79
33.7 per cent incidence 24 per cent incidence 8.7 per cent incidence 3.5 per cent incidence.
It is estimated that 16,000 women die yearly in the United States of cancer of the cervix. Unfortunately early cancer of the cervix is practically asymptomatic. Too much emphasis has been placed on abnormal discharge and bleeding, which are actually symptoms of far advanced disease. There is no problem in diagnosing a large, cauliflower-like, friable, free-bleeding, ulcerating lesion. The difficult differential diagnosis comes from the benign-appearing erosion which is frequently cauterized without Papanicolaou smear or biopsy. With periodic examination and earlier diagnosis the present 25 to 30 per cent five year salvage could be raised to the 75 per cent now obtained in cases in which disease is limited to the cervix. One of the oldest methods of .identifying squamous cell carcinoma of the cervix is that of Schiller. In 1926 he showed that normal squamous cells stain a mahogany color with iodine, but that scars, cysts and dyskeratotic and cancerous lesions do not. These either fail to stain at all or are of a pale color because they contain little or no glycogen. This is of great help in selecting the sites for biopsy and is also being used with that diagnostic instrument now being re-evaluated, the colposcope. High magnification may actually identify the cancerous cells in situ. Biopsy should be taken with a sharp knife or heavy biopsy punch. Bleeding is controlled by suture, cautery, insufflation with sulfadiazine powder, or packing with a gelatin sponge backed by gauze packing. It is difficult to outline the treatment of carcinoma of the cervix, because each case must be treated individually and the decision requires
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judgment and experience. A plea must be made for those physicians away from large centers to use the facilities at hand with which they are most familiar, whether these be x-ray, radium or surgery. The use of irradiation in any form presupposes special training in theory and technique. It is foolish for inadequately trained surgeons to tackle radical operation with node dissection, even the modified Wertheim operation. Proper training in surgery and experience in choice of cases, adequate blood and fluid replacement, modern anesthesia and good nursing care are essential to success. In treating cancer of the cervix one must consider the type and extent of the lesion and the general physical condition of the patient, including age and physiologic status. The ideal treatment for an early lesion in a woman seventy years of age usually would be unsatisfactory if applied to the same lesion in a woman thirty years of age. A factor of great importance is the ability of the examining physician to determine the extent of the disease by bimanual palpation. Unsuspected invasion has often occurred when it was thought that the carcinomatous lesion was only a surface one. Therefore such measures as cauterization, conization, cervical amputation and even classical hysterectomy should not be used in invasive carcinoma of the cervix. In the geriatric group, in the majority of instances the method of choice is that of high voltage x-ray irradiation followed by radium insertion. It must be remembered that patients receiving deep x-ray therapy in the older age group must be fortified with antianemic therapy and extra vitamins. The aging bone marrow does not stand the trauma of irradiation well. With suitable precautions and building up of the patient, excellent results may be obtained. The Body of the Uterus. The normal senile uterus is usually an atrophic, freely movable little organ, not over 2 inches in length. It should be nontender, smooth and symmetrical. If it is well supported and not elongated by prolonged prolapsus, it is usually completely asymptomatic. With stenosis of the internal os and collection of secretions above this, one may find the uterus enlarged, owing to pyometra. This occasionally happens in the absence of neoplastic disease. It is, of course, much more common with a tumor in the lower uterine segment or of the cervix, blocking off the passage of secretion. It is therefore significant to find in an elderly woman a uterus which is larger than the normal for her age group, particularly if it is tender. Cancer of the body of the uterus produces definite physical signs only when a sizable growth has occurred. A watery discharge may be noted which later becomes bloody, and actual tissue may be extruded. Fifty per cent of the cases of postmenopausal bleeding are due to adenocarcinoma. Other causes are benign polyps, excessive estrogen therapy, benign hyperplasia, submucous myoma and senile endometritis or endocervicitis. Investigation by dilatation and curettage is the only safe diagnostic
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method. Adequate secretions for Papanicolaou smear are obtained only when an endometrial aspirator is placed in the fundus of the uterus and the material is obtained from the top of the fundus. Myomas of the uterus usually regress after estrogen deprivation and may become calcified. It is not at all uncommon to find rocklike masses attached to the uterus. These are usually completely asymptomatic. The -presence of myomas, however, does not protect the patient from carcinoma, and, in the presence of bleeding, diagnostic curettage is manda. tory. Endometrial polyps, although histologically benign, are evidence of abnormal cellular activity. Patients in the geriatric group with these findings should be carefully watched for further disease. Carcinoma of the endometrium gives a good prognosis with early diagnosis, and prompt, adequate treatment results in 50 to 70 per cent of five year cures. The highest incidence as far as age is concerned occurs about ten years later than in those patients with carcinoma of the cervix. Recently there has been great speculation as to whether estrogen therapy or a high estrogen level might be a cause of cancer of the uterus. Much research has been done on this point, but at present there is no demonstrable etiologic relationship between estrogen and endometrial cancer. In contrast to cancer of the cervix, endometrial cancer is fundamentally a surgical disease. Wide panhysterectomy and bilateral salpingo-oophorectomy must be advised. Recent reports of Healy, Scheffey and Miller show that improved results can be obtained if the patient is given preoperative irradiation by radium or high voltage x-ray according to a planned routine. Only in the very aged or the very poor medical risk is irradiation alone advised. The Ovary. Ovarian neoplasms are among the most silent and insidious that we meet. The elderly woman who has either a pseudomucinous or serous cystadenoma of the ovary is fortunate in that there is usually a period during which complete surgical removal is possible. There are other patients who have both cystadenocarcinoma and solid carcinoma of the ovary without any apparent warning. Any palpable enlargement of adnexa in the geriatric group warrants laparotomy. The benign cystic tumors grow slowly and may reach large size without the patient's being aware of their presence, in the absence of complications. Complications of these tumors are torsion, with resulting circulatory embarrassment and necrosis; occasionally rupture; pressure on adjacent organs, and penetration of the capsule of the ovary if the disease becomes malignant. Once the limiting capsule is penetrated, carcinoma of the ovary becomes rapidly disseminated. Implants are found in the omentum, over the peritoneal surfaces of the bowels, the uterus, the cul-de-sac of Douglas, and elsewhere. Involvement of the ovary on the other side is the usual rule. The presence of ascites may be the first symtom which brings the patient to the doctor.
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Because of the occasional occurrence of Meigs' syndrome, namely, the presence of ascites and hydrothorax associated with a benign fibroma of the ovary, surgical exploration and a definitive diagnosis are always indicated. If the patient has malignancy and the primary mass can be removed by bilateral salpingo-oophorectomy and panhysterectomy, one's efforts at palliation with high voltage x-ray therapy can be made more effective. It is at times difficult to differentiate in these advanced cases between primary tumor of stomach and bowel with extension to the peritoneal cavity and to the ovary, and primary ovarian neoplasm with· extension to the peritoneal cavity and partial obstruction of the bowel. X-ray studies of the chest and bones are always indicated in these caees. If wide dissemination is present, it is still important to remove the primary lesion and consider palliation by irradiation. High voltage x-ray therapy is often the most helpful in controlling progress of the implants and formation of ascitic fluid. If fluid continues to form after paracentesis, the injection of radioactive isotopes, gold or phosphorus in sterile solution into the abdominal cavity may give definite palliation. SUMMARY AND CONCLUSIONS
1. The problems peculiar to the aging gynecologic patient have been outlined. With the judicious use of estrogenic hormone many infections and inflammatory processes of the skin and mucous membranes can be promptly relieved. 2. When the surgical approach to a lesion is the treatment of choice, one can in most instances give the patient the benefit of active treatment. Special attention must be devoted to preoperative and postoperative nutrition, replacement of fluids, electrolytes and blood, and early ambulation. The choice of technique requires the best judgment of both anesthesiologist and surgeon. 3. The problem of malignancy increases as the gynecologic patient ages. The breast, the body of the uterus, the cervix uteri and the vulva are particularly subject to malignant disease in the postmenopausal group. In the older patient, owing to slower growth of tumor, the prognosis may actually be better than in the younger patient. Prompt diagnosis and treatment are essential. REFERENCES 1. Faulkner, R. L., and Douglass, M.: Essentials of Obstetrical and Gynecological Pathology. 2nd ed. St. Louis, C. V. Mosby Company, 1951. 2. Palmer, J. P., and Biback, S. M.: Primary Cancer of the Vagina. Am. J. Obst. & Gynec., 67: 377,1954. 3. Herbut, P. A.: Gynecological and Obstetrical Pathology. Philadelphia, Lea & Febiger, 1953. 4. Conference on Therapy: Management of the Menopause. Am. J. Med., 10: 91. 1951.
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5. Pettit, M. deW.: Gynecological Conditions Found in Older Women. Geriatrics, 4: 353, 1949. 6. Corscaden, J. A.: Gynecologic Cancer. New York, Thomas Nelson and Son, 1951. 7. Howson, J. Y., and Montgomery, T. L.: Report of the Philadelphia Committee on Delay in Diagnosis of Pelvic Cancer. Am. J. Obst. & Gynec., 67: 109S, 1949. S. Ackerman, L. V., and Regato, J. A.: Cancer. St. Louis, C. V: Mosby Company, 1947. 9. Novak, E., and Novak, E. R.: Textbook of Gynecology. 4th ed. Baltimore, Williams & Wilkins Company, 1952. 10. Trout, H. F., and Benson, R. C.: Cancer of the Female Genital Tract. New York, American Cancer Society, Inc., 1954. (Monograph Series !fiS.) 1930 Spruce Street Philadelphia, Pa. (Dr. Pettit)
THE purpose of this article is to emphasize the gynecologic problems peculiar to the aging groups as opposed to those women who are premenopausal. It is obvious that the aging process comes at a markedly varying rate in different persons. Chronologic age is not always a fair index of the state of the patient's tissues and recuperative powers. As people in general become older, there will of necessity be increased hypertensive and cardiovascular renal disease; increased arteriosclerotic changes in cerebral, coronary and peripheral vessels; increased incidence of diabetes mellitus and of other degenerative processes, including the development of malignancy. In the woman, to these various processes must be added the very definite effects on tissue of estrogen deprivation. Attenuation of muscular and ligamentous structures occurs during the aging process. When estrogen deprivation is added, we find defects in supportive structures becoming much more obvious. These changes can also be important in the younger woman who has for some reason been deprived of her ovarian From the Department of Gynecology, Woman's Medical College of Pennsylvania, Philadelphia.
* Professor of Gynecology, Woman's Medical College of Pennsylvania; Chief of Gynecology, Hospital of the Woman's Medical College; Visiting Chief of Obstetrics and Gynecology, Philadelphia General Hospital,' Area Consultant in Gynecology, Veterans Administration, Philadelphia.
** Clinical Associate Professor in Gynecology, and Clinical Assistant Professor in Obstetrics, Woman's Medical College of Pennsylvania; Assistant Attending Physician in Obstetrics and Gynecology, Philadelphia General Hospital; Attending Physician in Gynecology and Obstetrics, Hospital of the Woman's Medical College, Philadelphia.
t Clinical Associate Professor in Obstetrics and Gynecology, Woman's Medical College of Pennsylvania; Assistant Attending Physician in Obstetrics and Gynecology, Philadelphia General Hospital; Attending Physician in Gynecology and obstetrics, Hospital of Woman's Medical College; Attending Gynecologist, U. S. Veterans Hospital, Philadelphia. 1627
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function at a relatively early age. Roentgenograms will often show marked osteoporosis in these women, explaining various joint and muscle symptoms. When major surgical problems exist in the geriatric woman, the importance of proper preoperative evaluation and supportive treatment, as well as proper anesthesia and postoperative care, cannot be overemphasized. Age in itself is no contraindication to necessary surgery. The presence of nutritional difficulty, usually over a long period, must be recognized. The presence of hypochlorhydria and achlorhydria frequently results in poor gastric absorption. This in turn results in chronic anemia, chronic hypoproteinemia and vitamin deficiency. To insure proper wound healing, these fundamental considerations must be adequately understood and remedied. GYNECOLOGIC EXAMINATION
Evaluation of the thyroid gland is part of a gynecologic examination in any age group. The presence of solitary nodules in the gland is a danger signal, and surgical excision should in most cases be seriously contemplated. Hypofunction and hyperfunction should be evaluated and treated according to the patient's needs. Thorough examination of the breasts should precede every pelvic examination. In women who are still having some estrogenic function, cystic changes and other benign situations may well be encountered. These usually disappear after the patient's menstrual function has ceased. When her tissues show definite signs of atrophy, any mass which appears in the breast should be treated as carcinoma until it is proved to be otherwise. History of nipple discharge should be elicited. Adequate exposure of the breasts, with removal of sufficient clothing and a good light, is important in evaluating skin changes in the nipple area. The patient should be examined in both the sitting and the recumbent positions. Again, sufficient time must be taken to examine the breasts with the patient's arms elevated and at her side and with the pectoral muscles relaxed, so that skin retraction and other evidence of deep tumors may be picked up. It is unfortunate that a number of elderly women will hide known masses for many months. Some of these tumors, however, may be of the slow-growing variety, and it is not too late to offer at least palliative help by surgery. The nursing problem and discomfort due to an ulcerating, sloughing mass can usually be prevented by simple mastectomy. It will be necessary to individualize each patient according to her medical status, as to the advisability of radical surgery versus simple mastectomy and high voltage x-ray therapy. Careful abdominal expmination is of necessity the next step before examination of the pelvic organs as such. The patient who is older must be placed in as comfortable a position as possible in order to favor relaxation of the abdominal musculature. Many of these women are arthritic
Geriatric Gynecology
1629
and have rigid deformities of their cervical spines. The placing of a suitable small pillow or folded towel at the base of the patient's head will help her to cooperate. Similarly, adjustment of the stirrups should be made to permit patients with arthritis of the lower extremities to be comfortable in the lithotomy position. The abdomen should be examined for previous scars, for hernia and for unusual masses and enlarged organs. If the abdomen is distended, is the distention due to fluid or gas in the intestines? Observation should be made of enlargement of the liver, presence or absence of omental "cake," the consistency and degree of encapsulation of varying masses. Many of these older people have such relaxed abdominal muscles that palpation of the organs is relatively easy. Ventral hernia and inguinal and femoral hernia are frequently found in these aging persons. The presence or absence of inguinal adenopathy should be ascertained. Pelvic Examination
For accurate evaluation of any gynecologic patient the removal of sufficient clothing, the emptying of bladder and bowel, and the placement of the patient in a suitable position are mandatory. The lithotomy position is most generally acceptable. The occasional use of the knee-chest or the Sims' position will make the visualization much easier of some lesions such as fistulas high in the anterior vaginal vault. Assorted specula of suitable length and width are easily obtainable. An adequate source of light, which can be adjusted to the individual situation, is a must. The Vulva and Vagina. The diseases of the vulvar skin and vaginal mucosa are many. Probably one of the most frequent complaints which bring an older patient to a gynecologist is vaginal discharge of some type, plus or minus itching or burning. We all have had the experience of seeing an obese patient with reddening and edema of the external genitalia and purulent, irritating discharge, a typical Candidiasis, prove to be diabetic. For completeness and brevity we shall divide the diseases of the vulva and vagina into four classes: INFLAMMATORY DISEASES. All vulvar and vaginal tissues which are daprived of estrogen are prone to trauma and infection. These tissues have poor recuperative powers. It is important to identify the predominant infectious organism in the secretions. Two simple office procedures will eliminate the presence of Trichomonas vaginitis and Candidiasis. The use of a saline suspension of secretions will show the actively motile trichomonads under the dry high power of the microscope. Ten per cent potassium hydroxide solution, one drop added to one drop of the previous saline suspension, will show up the mycelia in Candidiasis. It is most important to supply estrogen locally and sometimes orally to give the tissues recuperative power to combat the infestation. It is also important not to overtreat with any chemicals. Estrogen creme or vaginal supposi-
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M. D. Pettit, C. B. Hess, J. M. Leibfried
tories will improve the mucosa and acidify the secretions. If patients fail to respond to this alone, specific chemotherapy may then be used. Some patients will have a nonspecific infection, which usually responds to estrogenic therapy alone. If elderly women are receiving large doses of antibiotics for any reason, the danger of yeast infestation in the vagina must be constantly kept in mind. Suitable supplements of vitamins B, C and E in the diet are helpful in prevention. Periodic check-up every three to four months may prevent annoying exacerbations. Most douches are drying and mechanically irritating and should usually be avoided in the geri,atric group. Pediculosis, scabies, fungous infection, allergic dermatoses, psoriasis, lichen planus and other dermatologic conditions present their own specific problems. Urinalysis followed by blood sugar determination and glucose tolerance test when indicated must be thought of when diabetes mellitus is a possibility. Anemia and leukemia can be ruled out by blood count. LEUKOPLAKIC VULVITIS AND KRAUROSIS VULVAE. Leukoplakia of the vulva with thickening of the skin and fissuring is considered to be a definitely precancerous lesion. The thinned and atrophic dermis will seldom undergo malignant degeneration and can be safely built up with estrogenic therapy. When in doubt, a biopsy can be easily and safely performed. The serious lesions usually produce severe pruritus and burning, and the patient will seek relief of these symptoms. If true leukoplakia exists, vulvectomy should be considered. Patients will have complete relief of itching from excision of the affected skin. There is some likelihood of recurrence of the process in adjacent areas, so that follow-up is necessary. Alcohol and other injected materials are not advised in this group because of the danger of malignancy. Large doses of vitamin A and judicious use of estrogenic hormone will help prevent recurrence. The presence of neurogenic dermatitis with the "itch scratch" cycle often complicates both the hypertrophic and atrophic situations. At times the patient may complain bitterly of itching and burning when no skin lesions are obvious. Reassurance about cancer, emollient medication, sedation, bed rest and even hospitalization may be needed to break into this sort of cycle. Many women with atrophic changes will complain of severe dyspareunia. The propl?r use of lubricants with coitus and the supplementary use of estrogens locally and by mouth will be most helpful. It may even be necessary to do a minor plastic operation to enlarge the introitus in certain patients. BENIGN CYSTS AND NEOP'LASTIC DISEASE. Elderly women may suffer infection in sebac.eous cysts necessitating antibiotics, incision and drainage. New inclusion cysts and cysts of Bartholin's glands rarely occur for the first time in the older age group. Carcinoma (adenocarcinoma) of Bartholin's gland can occur, but is rare.
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Any nodule appearing on the vulva in older women should be examined carefully in a good light. Virus warts, senile keratosis and nevi can be recognized as such. Melanoma is a dangerous lesiop. and may occur in this area. Hydradenoma is rare."The most usual malignant lesion is squamous cell carcinoma. Rarely a basal cell epithelioma may be found. These epitheliomatous lesions usually appear raised, will have rolled edges, and are firm to touch in comparison to surrounding tissue. At first they may be insensitive, but later, as they enlarge, they cause itching and burning. As ulceration develops, secondary infection will cause pain. This is frequently the time when the patient first seeks assistance. In the study conducted by the Philadelphia Committee on Delay in Diagnosis of Pelvic Cancer, physician delay in vulvar cancer cases averaged nineteen months. Patient delay is an even greater factor, since patients tend to try all sorts of home remedies before asking for medical help. It should be assumed that about 50 per cent of cases of vulvar epithelioma with ulceration will have extension to inguinal nodes. The most successful treatment is wide surgical excision of the vulva and bilateral inguinal n.ode dissection. This may be done in two or three stages in poor operative risks. Symptomatic relief in the very elderly may be obtained by simple vulvectomy alone. High voltage x-ray therapy may have palliative value, but is rarely curative. Local radium or radon application is most unsatisfactory. Biopsy of suspicious lesions should be by excision rather than incision. With prompt and adequate surgery, when inguinal nodes are not yet involved, 80 per cent five year survival may be expected. When the nodes are involved, the survival rate drops to about 30 per cent. Vaginal carcinoma is usually secondary to cervix, corpus or vulvar lesions. When this diagnosis is suspected, careful search must be made for a primary site of origin. The posterior fornix is the most likely site in the rare primary tumor. Treatment is by radical surgery if possible, but may of necessity be confined to palliative irradiation. STRUCTURAL DEFECTS. Many patients will be certain that a true neoplasm exists, and on examination will prove to have prolapsus of the uterus, plus cystocele, enterocele and rectocele. The original injury which laid the groundwork for these lesions usually occurred as a result of childbirth many years before. The typical history will often be given of a severe upper respiratory infection with prolonged cough; with unusual physical exercise, lifting, straining, and the like. Suddenly the structura.1 defect appears, and the patient is sure she has a tumor. Associated dysfunction of the urinary tract and of the gastrointestinal tract plus pain and discomfort are frequent acompaniments of this type of lesion. In the past it was customary to fit these old ladies with a pessary and stop at that. With the advent of modern anesthesia, the use of early ambulation, the use of sufficient blood replacement and careful preopera-
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M. D. Pettit, C. B. Hess, J. M. Leibfried
tive medical evaluation, it is now possible to give more permanent relief to these patients. The choice of procedure will of course be determined by the life expectancy and by the expectancy of physical activity of the patient. It is exceedingly important in the geriatric group to maintain physical activity as long as the patient can manage this. The sense of being able to help in the household and of being able to get around and lead a reasonably active life is what makes life worth living for many of these people. A pessary must be cleansed frequently and does not always prevent progression of the condition. If it is felt that the patient will live long enough and she plans to continue to be active while wearing her pessary, the cystocele and prolapsus will usually increase in intensity. The time may come when proper fitting with a pessary is no longer practicable. By that time it may be tdo late for hope of good result from surgery. Each patient should be evaluated on her own merits in that regard. For the elderly woman who is not going to be active, climb stairs, and so on, and who is past the likelihood of sexual activity, the LeFort operation, or colpocleisis, is a satisfactory operation. This may be done on poor operative risks, using procaine local infiltration anesthesia. Dilatation and curettage should always precede the repair. The only difficulty in performing this procedure will come if the patient cannot keep her legs apart and in the stirrups for a sufficient length of time. Usually the use of morphine and atropine, or other suitable narcotic adjuvant, will make this procedure possible even in a poor medical risk. ,JThe Manchester-Fothergill operation does not invade the peritoneal cavity and will give satisfactory results with associated repair of other lacerations in properly chosen cases. This must, of course, be preceded by a diagnostic curettage. Most people feel that vaginal hysterectomy is a satisfactory method of handling the severe procidentia group. Elderly patients appear to tolerate the vaginal approach better than the abdominal one. In cases of severe and recurrent enterocele it may be necessary to combine the vaginal and abdominal approach. This lesion is the one most apt to recur after any repair operation. Postmenopausal bloody discharge is a frequent complaint bringing the patient to a gynecologist. The necessity then arises for determining the site of origin of the bleeding. Because of the fragility of elderly tissues it is possible that local trauma, particularly scratching or improper douching, may cause bleeding from the vulvar and perineal surfaces. The presence of an ulcerated neoplasm on the vulva or adjacent structures may be responsible. Urethral caruncle and ectropion are frequent sources of spotting in this age group. An intravesical lesion, either polyp or neoplasm, may be responsible. A decubitus ulcer on a prolapsed cervix may cause bloody discharge on the clothing. Carcinoma of the cervix must be ruled out. Digital and speculum examination of the rectum will rule out hemorrhoids, fissures and local neoplastic growths. Many of these patients will
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show an obvious reason for the bleeding in one of these sites. It must be remembered that carcinoma of the endometrium is the most statistically likely neoplasm in the geriatric group. Because elderly cervices are apt to be stenotic, the passage of both foul and bloody discharge is likely to be periodic. It is necessary to build up a certain pressure in the cavity of the uterus before the discharge is expressed with a gush. Diagnostic curettage is the only safe method of eliminating this possibility. The Cervix. Diseases of the cervix must be ruled out in elderly patients complaining of abnormal discharge. However, owing to marked atrophic changes coming after estrogen deprivation, the cervix is usually a tiny, button-like organ. Polyps are frequently found and are usually benign. It is unusual to find the inflammatory and eroded cervices seen in younger women. The statistics on the incidence of cervical malignancy by age are as follows: Aged Aged Aged Aged
40-49 50--59 60-69 70-79
33.7 per cent incidence 24 per cent incidence 8.7 per cent incidence 3.5 per cent incidence.
It is estimated that 16,000 women die yearly in the United States of cancer of the cervix. Unfortunately early cancer of the cervix is practically asymptomatic. Too much emphasis has been placed on abnormal discharge and bleeding, which are actually symptoms of far advanced disease. There is no problem in diagnosing a large, cauliflower-like, friable, free-bleeding, ulcerating lesion. The difficult differential diagnosis comes from the benign-appearing erosion which is frequently cauterized without Papanicolaou smear or biopsy. With periodic examination and earlier diagnosis the present 25 to 30 per cent five year salvage could be raised to the 75 per cent now obtained in cases in which disease is limited to the cervix. One of the oldest methods of .identifying squamous cell carcinoma of the cervix is that of Schiller. In 1926 he showed that normal squamous cells stain a mahogany color with iodine, but that scars, cysts and dyskeratotic and cancerous lesions do not. These either fail to stain at all or are of a pale color because they contain little or no glycogen. This is of great help in selecting the sites for biopsy and is also being used with that diagnostic instrument now being re-evaluated, the colposcope. High magnification may actually identify the cancerous cells in situ. Biopsy should be taken with a sharp knife or heavy biopsy punch. Bleeding is controlled by suture, cautery, insufflation with sulfadiazine powder, or packing with a gelatin sponge backed by gauze packing. It is difficult to outline the treatment of carcinoma of the cervix, because each case must be treated individually and the decision requires
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M. D. Pettit, C. B. Hess, J. M. Leibfried
judgment and experience. A plea must be made for those physicians away from large centers to use the facilities at hand with which they are most familiar, whether these be x-ray, radium or surgery. The use of irradiation in any form presupposes special training in theory and technique. It is foolish for inadequately trained surgeons to tackle radical operation with node dissection, even the modified Wertheim operation. Proper training in surgery and experience in choice of cases, adequate blood and fluid replacement, modern anesthesia and good nursing care are essential to success. In treating cancer of the cervix one must consider the type and extent of the lesion and the general physical condition of the patient, including age and physiologic status. The ideal treatment for an early lesion in a woman seventy years of age usually would be unsatisfactory if applied to the same lesion in a woman thirty years of age. A factor of great importance is the ability of the examining physician to determine the extent of the disease by bimanual palpation. Unsuspected invasion has often occurred when it was thought that the carcinomatous lesion was only a surface one. Therefore such measures as cauterization, conization, cervical amputation and even classical hysterectomy should not be used in invasive carcinoma of the cervix. In the geriatric group, in the majority of instances the method of choice is that of high voltage x-ray irradiation followed by radium insertion. It must be remembered that patients receiving deep x-ray therapy in the older age group must be fortified with antianemic therapy and extra vitamins. The aging bone marrow does not stand the trauma of irradiation well. With suitable precautions and building up of the patient, excellent results may be obtained. The Body of the Uterus. The normal senile uterus is usually an atrophic, freely movable little organ, not over 2 inches in length. It should be nontender, smooth and symmetrical. If it is well supported and not elongated by prolonged prolapsus, it is usually completely asymptomatic. With stenosis of the internal os and collection of secretions above this, one may find the uterus enlarged, owing to pyometra. This occasionally happens in the absence of neoplastic disease. It is, of course, much more common with a tumor in the lower uterine segment or of the cervix, blocking off the passage of secretion. It is therefore significant to find in an elderly woman a uterus which is larger than the normal for her age group, particularly if it is tender. Cancer of the body of the uterus produces definite physical signs only when a sizable growth has occurred. A watery discharge may be noted which later becomes bloody, and actual tissue may be extruded. Fifty per cent of the cases of postmenopausal bleeding are due to adenocarcinoma. Other causes are benign polyps, excessive estrogen therapy, benign hyperplasia, submucous myoma and senile endometritis or endocervicitis. Investigation by dilatation and curettage is the only safe diagnostic
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method. Adequate secretions for Papanicolaou smear are obtained only when an endometrial aspirator is placed in the fundus of the uterus and the material is obtained from the top of the fundus. Myomas of the uterus usually regress after estrogen deprivation and may become calcified. It is not at all uncommon to find rocklike masses attached to the uterus. These are usually completely asymptomatic. The -presence of myomas, however, does not protect the patient from carcinoma, and, in the presence of bleeding, diagnostic curettage is manda. tory. Endometrial polyps, although histologically benign, are evidence of abnormal cellular activity. Patients in the geriatric group with these findings should be carefully watched for further disease. Carcinoma of the endometrium gives a good prognosis with early diagnosis, and prompt, adequate treatment results in 50 to 70 per cent of five year cures. The highest incidence as far as age is concerned occurs about ten years later than in those patients with carcinoma of the cervix. Recently there has been great speculation as to whether estrogen therapy or a high estrogen level might be a cause of cancer of the uterus. Much research has been done on this point, but at present there is no demonstrable etiologic relationship between estrogen and endometrial cancer. In contrast to cancer of the cervix, endometrial cancer is fundamentally a surgical disease. Wide panhysterectomy and bilateral salpingo-oophorectomy must be advised. Recent reports of Healy, Scheffey and Miller show that improved results can be obtained if the patient is given preoperative irradiation by radium or high voltage x-ray according to a planned routine. Only in the very aged or the very poor medical risk is irradiation alone advised. The Ovary. Ovarian neoplasms are among the most silent and insidious that we meet. The elderly woman who has either a pseudomucinous or serous cystadenoma of the ovary is fortunate in that there is usually a period during which complete surgical removal is possible. There are other patients who have both cystadenocarcinoma and solid carcinoma of the ovary without any apparent warning. Any palpable enlargement of adnexa in the geriatric group warrants laparotomy. The benign cystic tumors grow slowly and may reach large size without the patient's being aware of their presence, in the absence of complications. Complications of these tumors are torsion, with resulting circulatory embarrassment and necrosis; occasionally rupture; pressure on adjacent organs, and penetration of the capsule of the ovary if the disease becomes malignant. Once the limiting capsule is penetrated, carcinoma of the ovary becomes rapidly disseminated. Implants are found in the omentum, over the peritoneal surfaces of the bowels, the uterus, the cul-de-sac of Douglas, and elsewhere. Involvement of the ovary on the other side is the usual rule. The presence of ascites may be the first symtom which brings the patient to the doctor.
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M. D. Pettit, C. B. Hess, J. M. Leibfried
Because of the occasional occurrence of Meigs' syndrome, namely, the presence of ascites and hydrothorax associated with a benign fibroma of the ovary, surgical exploration and a definitive diagnosis are always indicated. If the patient has malignancy and the primary mass can be removed by bilateral salpingo-oophorectomy and panhysterectomy, one's efforts at palliation with high voltage x-ray therapy can be made more effective. It is at times difficult to differentiate in these advanced cases between primary tumor of stomach and bowel with extension to the peritoneal cavity and to the ovary, and primary ovarian neoplasm with· extension to the peritoneal cavity and partial obstruction of the bowel. X-ray studies of the chest and bones are always indicated in these caees. If wide dissemination is present, it is still important to remove the primary lesion and consider palliation by irradiation. High voltage x-ray therapy is often the most helpful in controlling progress of the implants and formation of ascitic fluid. If fluid continues to form after paracentesis, the injection of radioactive isotopes, gold or phosphorus in sterile solution into the abdominal cavity may give definite palliation. SUMMARY AND CONCLUSIONS
1. The problems peculiar to the aging gynecologic patient have been outlined. With the judicious use of estrogenic hormone many infections and inflammatory processes of the skin and mucous membranes can be promptly relieved. 2. When the surgical approach to a lesion is the treatment of choice, one can in most instances give the patient the benefit of active treatment. Special attention must be devoted to preoperative and postoperative nutrition, replacement of fluids, electrolytes and blood, and early ambulation. The choice of technique requires the best judgment of both anesthesiologist and surgeon. 3. The problem of malignancy increases as the gynecologic patient ages. The breast, the body of the uterus, the cervix uteri and the vulva are particularly subject to malignant disease in the postmenopausal group. In the older patient, owing to slower growth of tumor, the prognosis may actually be better than in the younger patient. Prompt diagnosis and treatment are essential. REFERENCES 1. Faulkner, R. L., and Douglass, M.: Essentials of Obstetrical and Gynecological Pathology. 2nd ed. St. Louis, C. V. Mosby Company, 1951. 2. Palmer, J. P., and Biback, S. M.: Primary Cancer of the Vagina. Am. J. Obst. & Gynec., 67: 377,1954. 3. Herbut, P. A.: Gynecological and Obstetrical Pathology. Philadelphia, Lea & Febiger, 1953. 4. Conference on Therapy: Management of the Menopause. Am. J. Med., 10: 91. 1951.
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5. Pettit, M. deW.: Gynecological Conditions Found in Older Women. Geriatrics, 4: 353, 1949. 6. Corscaden, J. A.: Gynecologic Cancer. New York, Thomas Nelson and Son, 1951. 7. Howson, J. Y., and Montgomery, T. L.: Report of the Philadelphia Committee on Delay in Diagnosis of Pelvic Cancer. Am. J. Obst. & Gynec., 67: 109S, 1949. S. Ackerman, L. V., and Regato, J. A.: Cancer. St. Louis, C. V: Mosby Company, 1947. 9. Novak, E., and Novak, E. R.: Textbook of Gynecology. 4th ed. Baltimore, Williams & Wilkins Company, 1952. 10. Trout, H. F., and Benson, R. C.: Cancer of the Female Genital Tract. New York, American Cancer Society, Inc., 1954. (Monograph Series !fiS.) 1930 Spruce Street Philadelphia, Pa. (Dr. Pettit)