Introduction
This comparative case study explores the treatment options for vaginal atrophy in a 57-year-Mrs. Anderson is a pseudo-name. Reduced estrogen levels in the body before and after menopause are the primary cause of vaginal shrinkage (Donders et al., 2019). Vaginal tissues rely heavily on estrogen to stay healthy and functional. Vaginal tissues become more fragile, less elastic, and more prone to dryness, inflammation, and irritation as estrogen levels fall (Donders et al., 2019). In this case, Mrs. Anderson, who presented with vaginal dryness, itching, and pain during intercourse best treatment option is explored. This will involve examining two treatment options, systemic and topical estrogen therapy, and evaluating their relative efficacy. Treatment is tailored to the individual patient based on their condition, goals, and clinical presentation.
Setting and Social Dynamics
Mrs. Anderson visits a community clinic for help. Her husband is very supportive, and they share a home. Her resolve to seek treatment for her problems indicates her desire to enhance her life and foster a satisfying sexual connection.
Subjective Information
Mrs. Anderson presented with chief complaints of vaginal dryness, itching, and pain during intercourse. Her symptoms began six months prior to the clinic visit and have progressively worsened. It all started with a persistent sensation of dryness in her vaginal area, which caused discomfort and irritation due to a lack of moisture. This dryness was accompanied by a history of pain during sexual intercourse, initially starting as discomfort and gradually progressing to a sharp, burning pain. As a result, Mrs. Anderson’s sexual relationship with her partner has been affected. Additionally, she has experienced persistent itching in her vaginal region, occurring at any time and causing constant discomfort. Although the itching episodes would come and go, they have been a constant source of discomfort for her. Mrs. Anderson denies any abnormal vaginal bleeding, unusual vaginal discharge, increased frequency of urination, burning sensation during urination, or lower abdominal pain.
The patient’s past medical history reveals a five-year diagnosis of hypertension, for which she has been prescribed nifedipine 20mg once daily and hydrochlorothiazide 12.5 once daily. There are no known allergies to food, drugs, or environmental factors, and no history of blood transfusion or radiation exposure. Additionally, she has not been involved in any road traffic accidents. Regarding past surgical interventions, there have been none. Regarding family history, she is the firstborn of two siblings, with a living and healthy brother. The family has a history of chronic illness; her mother passed away at 78 years old and her father at 83 due to hypertension. In her social life, the patient is married and resides with her husband and two healthy children. She does not smoke and occasionally consumes alcohol. Her diet is balanced and regular. During the review of systems, the patient reports experiencing fatigue but denies any history of cough, difficulty breathing, abdominal pain, vomiting, lower abdominal pain, joint pain, or headaches.
Objective Information
On physical exam, the vital signs are within normal limits: HR 76bpm, BP 128/78 mmHg, Temp 98.7F, RR 16 breaths per minute, and SpO2 98%. The patient’s anthropometric measurements are Height 5.7ft, Weight 140lbs, and BMI 21.1 kg/m2 (Normal). Pelvic examination reveals thin, pale vaginal mucosa with loss of rugae and reduced elasticity. The vaginal pH is 6.5, and there is tenderness upon palpation of the posterior vaginal wall.
Medical Decision-Making and Clinical Impression
A definitive diagnosis of vaginal atrophy was made after ruling out the two other differentials. The differentials were vulvovaginal candidiasis and vulvar dermatitis. Vulvovaginal candidiasis was ruled out as while vaginal dryness can also be a symptom of a yeast infection, the absence of significant abnormal discharge, such as a thick, white, cottage cheese-like discharge, and the lack of urinary symptoms made it less likely. On the other hand, vulvar dermatitis was ruled out as the absence of abnormal discharge, urinary symptoms, or other associated signs of dermatitis (such as redness, swelling, or rash) made this differential less likely.
The diagnosis of vaginal atrophy was chosen as the symptoms described by Mrs. Anderson, including vaginal dryness, itching, and pain during intercourse, are classic features of vaginal atrophy. The gradual onset and progressive worsening of symptoms over six months, along with the absence of abnormal vaginal bleeding, unusual discharge, or urinary symptoms, further support this diagnosis.
Introduction of Two Treatment Options
Vaginal atrophy can be treated with systemic or topical estrogen therapy, both of which have shown efficacy in clinical trials. Rashidi Fakari et al. (2020) found that treatment with systemic estrogen effectively reduced vaginal atrophy symptoms. Women who had experienced menopause and were experiencing moderate-to-severe symptoms were enrolled in the trial and given oral or transdermal estrogen treatment. Vaginal dryness, itching, and dyspareunia were significantly reduced, and the results were met with a favorable safety profile.
Potter & Panay (2020) conducted a comprehensive study to assess the efficacy of topical estrogen treatment for vaginal atrophy. Vaginal estrogen was studied in various forms (cream, tablet, and ring) and compared to placebo or non-hormonal therapy in the reviewed randomized controlled studies. Topical estrogen therapy was associated with a significant reduction in vaginal symptoms and improvement in vaginal health without significant systemic absorption, according to the results (Potter & Panay, 2020).
Comparison and Contrast of Treatment Options:
Treatment of vaginal atrophy with systemic estrogen therapy has the added benefit of alleviating other menopausal symptoms, such as hot flashes and night sweats (Ghorbani & Mirghafourvand, 2020). The likelihood of systemic adverse effects, such as breast soreness, nausea, and thromboembolic events, is slightly higher (Ghorbani & Mirghafourvand, 2020). However, topical estrogen therapy is less likely to cause systemic side effects because of its more localized action and lower systemic absorption. It is excellent for relieving vaginal discomfort but may not help with other menopausal issues (Hirschberg et al., 2021).
Analysis of Research Merit and Soundness:
Studies on systemic estrogen therapy generally demonstrate research merit and soundness. Randomized controlled trials (RCTs) are commonly used, providing robust evidence. Adequate sample sizes, validated measures, and monitoring of adverse effects contribute to research quality (Rashidi Fakari et al., 2020). However, concerns exist regarding long-term use and associated risks. Research on topical estrogen therapy also shows research merit and soundness. RCTs and observational studies are utilized, with larger sample sizes improving reliability (Potter & Panay, 2020). Validated measures and standardized protocols enhance the validity of findings. Variability in techniques may impact research quality, necessitating further investigation.
Chosen Treatment Option and Justification
Topical estrogen therapy is the preferred method for Mrs. Anderson because it offers targeted treatment by directly addressing the vaginal tissues affected by atrophy. Topical estrogen therapy minimizes systemic absorption, reducing the risk of experiencing systemic side effects associated with estrogen use (Laing et al., 2022). This approach provides a favorable safety profile, mitigating potential risks such as an increased risk of blood clots or breast cancer. The estrogen cream replenishes moisture, improves vaginal health, and enhances comfort during sexual intercourse (Minkin, 2019). This tailored approach addresses Mrs. Anderson’s distressing symptoms, improving her quality of life and maintaining a satisfying sexual relationship with her spouse.
Specific Plans and Interventions:
Mrs. Anderson will apply a vaginal estrogen cream with a low dose intravaginally twice weekly for the first three to four weeks (Crandall et al., 2020). After that, she will apply the cream once or twice weekly for maintenance. To ensure proper administration and maximize the effectiveness of the treatment (Palacios et al., 2019), Mrs. Anderson will receive detailed instructions on how to apply the cream intravaginally. This will include guidance on the appropriate amount to use, insertion technique, and hygiene practices to follow (Palacios et al., 2019). Regular check-ins will be organized to facilitate the tracking of progress and the implementation of any necessary modifications to the treatment plan (Arthur et al., 2021).
Cultural and Socioeconomic Considerations:
Cultural and socioeconomic considerations are crucial in providing equitable and inclusive care for patients (Sindhuja Giritharan, 2020). Mrs. Anderson’s cultural background and preferences will be respected throughout treatment, understanding that cultural beliefs, practices, and values may influence a patient’s perception of illness and treatment options (Sindhuja Giritharan, 2020). In addition to cultural considerations, the socioeconomic aspect of Mrs. Anderson’s case will be considered. Affordability and accessibility of the prescribed medication, such as topical estrogen therapy, will be carefully evaluated. Ensuring that the recommended treatment option is financially feasible for Mrs. Anderson and aligns with her resources (Higgins et al., 2022). In case of financial challenges, alternative options, such as lower-cost formulations and assistance programs, can help. Also, proximity to a pharmacy, transportation limitations, and mobility issues will be considered to ensure that Mrs. Anderson can conveniently obtain the medication and adhere to the treatment regimen (Higgins et al., 2022). By incorporating cultural and socioeconomic considerations into Mrs. Anderson’s treatment plan, the healthcare team aims to provide personalized and patient-centered care (Higgins et al., 2022).
Conclusion
In conclusion, after analyzing the treatment options for vaginal atrophy, topical estrogen therapy emerged as the preferred method for Mrs. Anderson. It offers targeted treatment with minimal systemic side effects, effectively addressing her distressing symptoms. Detailed instructions will be provided for proper administration, and regular check-ins will be scheduled to monitor progress and make any necessary adjustments. Cultural and socioeconomic factors will be considered to ensure personalized and inclusive care. By choosing topical estrogen therapy, Mrs. Anderson’s quality of life will improve, and her sexual relationship will be maintained.
References
Arthur, S. S., Dorfman, C. S., Massa, L. A., & Shelby, R. A. (2021). Managing female sexual dysfunction. Urologic Oncology: Seminars and Original Investigations. https://doi.org/10.1016/j.urolonc.2021.06.006
Crandall, C. J., Diamant, A., & Santoro, N. (2020). Safety of vaginal estrogens. Menopause, 27(3), 339–360. https://doi.org/10.1097/gme.0000000000001468
Donders, G. G. G., Ruban, K., Bellen, G., & Grinceviciene, S. (2019). Pharmacotherapy for the treatment of vaginal atrophy. Expert Opinion on Pharmacotherapy, 20(7), 821–835. https://doi.org/10.1080/14656566.2019.1574752
Ghorbani, Z., & Mirghafourvand, M. (2020). The efficacy and safety of intravaginal oxytocin on vaginal atrophy: A systematic review. Post Reproductive Health, 205336912094664. https://doi.org/10.1177/2053369120946645
Higgins, J. A., Lands, M., Ufot, M., & McClelland, S. I. (2022). Socioeconomics and Erotic Inequity: A Theoretical Overview and Narrative Review of Associations Between Poverty, Socioeconomic Conditions, and Sexual well-being. The Journal of Sex Research, 59(8), 940–956. https://doi.org/10.1080/00224499.2022.2044990
Hirschberg, A. L., Bitzer, J., Cano, A., Ceausu, I., Chedraui, P., Durmusoglu, F., Erkkola, R., Goulis, D. G., Kiesel, L., Lopes, P., Pines, A., van Trotsenburg, M., Lambrinoudaki, I., & Rees, M. (2021). Topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: An EMAS clinical guide. Maturitas, 148, 55–61. https://doi.org/10.1016/j.maturitas.2021.04.005
Laing, A. J., Newson, L., & Simon, J. A. (2022). Individual Benefits and Risks of Intravaginal Estrogen and Systemic Testosterone in the Management of Women in the Menopause, With a Discussion of Any Associated Risks for Cancer Development. The Cancer Journal, 28(3), 196–203. https://doi.org/10.1097/ppo.0000000000000598
Minkin, M. J. (2019). Menopause. Obstetrics and Gynecology Clinics of North America, 46(3), 501–514. https://doi.org/10.1016/j.ogc.2019.04.008
Palacios, S., Nappi, R. E., Shapiro, M., de Melo, N. R., Wender, M. C. O., Fernandes, C. E., Pardini, D., Machado, R. B., Kulak, J. J., Celis-González, C., Martino, M. T., Pizzi, R. R., Villaseca, P., Storch, E., Danckers, L. F., & Hernández-Bueno, J. A. (2019). An individualized approach to the management of vaginal atrophy in Latin America. Menopause, 26(8), 919. https://doi.org/10.1097/GME.0000000000001368
Potter, N., & Panay, N. (2020). Vaginal lubricants and moisturizers: a review into use, efficacy, and safety. Climacteric, 24(1), 19–24. https://doi.org/10.1080/13697137.2020.1820478
Rashidi Fakari, F., Simbar, M., Nasab, M. B., Ghazanfarpour, M., & Rashidi Fakari, F. (2020). A Review of Pharmacological Treatments for Vaginal Atrophy in Postmenopausal Women in Iran. Journal of Menopausal Medicine, 26(2), 104–111. https://doi.org/10.6118/jmm.19021
Sindhuja Giritharan. (2020). Socio-cultural Perspectives, Challenges, and Approaches to Sexual Health in the Indian Subcontinent. https://doi.org/10.1007/978-3-030-36222-5_3
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