Benign Gynecologic Disorders in the Older Woman

  • Kimberly A. Gerten
  • W. Jerod Greer
  • C. Bryce Bowling
  • Thomas WheelerII
  • Holly E. Richter


Nonmalignant genital tract conditions and pelvic floor disorders including pelvic organ prolapse and incontinence are common gynecologic problems encountered by the older woman. With the rapidly increasing population of active older American women, physicians can expect to provide evaluation and treatment of these conditions with increasing frequency. These conditions are typically amenable to both medical and surgical therapies making individualization of treatment approaches important. An anatomically directed survey of nonneoplastic conditions of the lower and upper genital tract conditions is presented along with a discussion of pelvic floor support disorders common in the older woman. Evidenced-based evaluation and treatment suggestions are provided.


Urinary Incontinence Pelvic Floor Pelvic Organ Prolapse Bacterial Vaginosis Lichen Planus 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Partially supported by the National Institute of Diabetes and Digestive and Kidney Diseases, DK068389.


  1. 1.
    Nelson HD (2008) Menopause review. Lancet 371:760–770PubMedCrossRefGoogle Scholar
  2. 2.
    Grady D (2006) Clinical practice: management of menopausal symptoms. N Engl J Med 355:2338–2347PubMedCrossRefGoogle Scholar
  3. 3.
    Suckling J, Lethaby A, Kennedy R (2003) Local estrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev, Issue 4. Art. No.:CD0015000. doi:10.1002/14651858.CD001500.pub2Google Scholar
  4. 4.
    Simon J, Snabes M (2007) Menopausal hormone therapy for vasomotor symptoms: balancing the risks and benefits with ultra-low doses of estrogen. Expert Opin Investig Drugs 16:2005–2020PubMedCrossRefGoogle Scholar
  5. 5.
    Verdier-Sévrain S (2007) Effect of estrogens on skin aging and the potential role of selective estrogen receptor modulators. Climacteric 10:289–297PubMedCrossRefGoogle Scholar
  6. 6.
    Netter F. Reproductive system. The Netter Collection of Medical Illustrations, ed. O. E. Vol. 2. 1997, Philadelphia: Elsevier, p 90.Google Scholar
  7. 7.
    Beers M, Berkow R (2000) Aging and the skin. In: Lane K (ed) The Merck manual of geriatrics, 3rd edn. Merck Research Laboratories, Whitehouse Station, NJ, pp 1231–1238Google Scholar
  8. 8.
    Thomas RH et al (1996) Anogenital lichen sclerosus in women. J R Soc Med 89:694–698PubMedGoogle Scholar
  9. 9.
    Goldstein AT et al (2005) Prevalence of vulvar lichen sclerosus in a general gynecology practice. J Reprod Med 50:477–480PubMedGoogle Scholar
  10. 10.
    Meyrick TR, Kennedy C (1986) The development of lichen sclerosus et atrophicus in monozygotic twin girls. Br J Dermatol 114:377CrossRefGoogle Scholar
  11. 11.
    Todd P et al (1994) Lichen sclerosus and the Kobner phenomenon. Clin Exp Dermatol 19:262–263PubMedCrossRefGoogle Scholar
  12. 12.
    ACOG Practice Bulletin No. 93 (2008) Diagnosis and management of vulvar skin disorders. Obstet Gynecol 111:1243–1253CrossRefGoogle Scholar
  13. 13.
    Carli P et al (1995) Squamous cell carcinoma arising in vulval lichen sclerosus: a longitudinal cohort study. Eur J Cancer Prev 4:491–495PubMedCrossRefGoogle Scholar
  14. 14.
    Cooper SM et al (2004) Does treatment of vulvar lichen sclerosus influence its prognosis? Arch Dermatol 140:702–706PubMedCrossRefGoogle Scholar
  15. 15.
    Lorenz B, Kaufman RH, Kutzner SK (1998) Lichen sclerosus. Therapy with clobetasol propionate. J Reprod Med 43:790–794PubMedGoogle Scholar
  16. 16.
    Neill SM, Tatnall FM, Cox NH (2002) Guidelines for the management of lichen sclerosus. Br J Dermatol 147:640–649PubMedCrossRefGoogle Scholar
  17. 17.
    Renaud-Vilmer C et al (2004) Vulvar lichen sclerosus: effect of long-term topical application of a potent steroid on the course of the disease. Arch Dermatol 140:709–712PubMedCrossRefGoogle Scholar
  18. 18.
    Virgili A, Bacilieri S, Corazza M (2001) Managing vulvar lichen simplex chronicus. J Reprod Med 46:343–346PubMedGoogle Scholar
  19. 19.
    Shiohara T (1988) The lichenoid tissue reaction. An immunological perspective. Am J Dermatopathol 10:252–256PubMedCrossRefGoogle Scholar
  20. 20.
    Scully C, el-Kom M (1985) Lichen planus: review and update on pathogenesis. J Oral Pathol 14:431–458PubMedCrossRefGoogle Scholar
  21. 21.
    Ramer MA et al (2003) Lichen planus and the vulvovaginal-gingival syndrome. J Periodontol 74:1385–1393PubMedCrossRefGoogle Scholar
  22. 22.
    Droegemueller W (1992) Comprehensive gynecology, 2nd edn. Mosby, St. Louis, p 637Google Scholar
  23. 23.
    Visco AG, Del Priore G (1996) Postmenopausal bartholin gland enlargement: a hospital-based cancer risk assessment. Obstet Gynecol 87:286–290PubMedCrossRefGoogle Scholar
  24. 24.
    Bachmann GA et al (2006) Chronic vulvar and other gynecologic pain: prevalence and characteristics in a self-reported survey. J Reprod Med 51:3–9PubMedGoogle Scholar
  25. 25.
    Moyal-Barracco M, Lynch PJ (2004) 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. J Reprod Med 49:772–777PubMedGoogle Scholar
  26. 26.
    ACOG Committee Opinion No. 345 (2006) Vulvodynia. Obstet Gynecol 108:1049–1052CrossRefGoogle Scholar
  27. 27.
    Arnold LD et al (2007) Assessment of vulvodynia symptoms in a sample of US women: a prevalence survey with a nested case control study. Am J Obstet Gynecol 196:128 e1–e6CrossRefGoogle Scholar
  28. 28.
    Zoubina EV et al (2001) Acute and chronic estrogen supplementation decreases uterine sympathetic innervation in ovariectomized adult virgin rats. Histol Histopathol 16:989–996PubMedGoogle Scholar
  29. 29.
    Haefner HK et al (2005) The vulvodynia guideline. J Low Genit Tract Dis 9:40–51PubMedCrossRefGoogle Scholar
  30. 30.
    Rapkin AJ, McDonald JS, Morgan M (2008) Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome. Am J Obstet Gynecol 198:41 e1–e5CrossRefGoogle Scholar
  31. 31.
    Hillier S, Lau R (1997) Vaginal microflora in postmenopausal women who have not received estrogen replacement therapy. Clin Infect Dis 25:S123–126PubMedCrossRefGoogle Scholar
  32. 32.
    ACOG Practice Bulletin Number 72 (2006) Clinical management guidelines for obstetrician – gynecologists. Obstet Gynecol 107:1195–1206CrossRefGoogle Scholar
  33. 33.
    McEndree B (1999) Clinical application of the vaginal maturation index. Nurse Pract 24(51–52):55–56Google Scholar
  34. 34.
    Hendrix SL, Cochrane BB, Nygaard IE et al (2005) Effects of estrogen with and without progestin on urinary incontinence. JAMA 293:935–948PubMedCrossRefGoogle Scholar
  35. 35.
    Moehrer B, Hextall A, Jackson S (2003) Oestrogens for urinary incontinence in women. Cochrane Database Syst Rev, Issue 2. Art. No. CD 001405. doi:10.1002/14651858.CD001405Google Scholar
  36. 36.
    Perrotta C, Aznar M, Mejia R, et al. (2008) Oestrogens for preventing recurrent urinary tract infection in postmenopausal women. Cochrane Database Syst Rev, Issue 2. Art. No.: CD005131. doi:10.1002/14651858.CD005131.pub2Google Scholar
  37. 37.
    Anveden-Hertzberg L, Gauderer MW, Elder JS (1995) Urethral prolapse: an often misdiagnosed cause of urogenital bleeding in girls. Pediar Emerg Care 11:212–214CrossRefGoogle Scholar
  38. 38.
    Redman JF (1982) Conservative management of urethral prolapse in female children. Urology 19:505–506PubMedCrossRefGoogle Scholar
  39. 39.
    Wright M (1987) Urethral prolapse in children – alternative management. S Afr Med J 72:551–552PubMedGoogle Scholar
  40. 40.
    Kleinjan JH, Vos P (1984) Strangulated urethral prolapse. J Urol 132:732–733Google Scholar
  41. 41.
    Park DS, Cho TW (2004) Simple solution for urethral caruncle. J Urol 172:1184–1185Google Scholar
  42. 42.
    Aspera AM, Rackley RR, Vasavada SP (2002) Contemporary evaluation and management of the female urethral diverticulum. Urol Clin North Am 29:617–624PubMedCrossRefGoogle Scholar
  43. 43.
    Pandit L, Ouslander JG (1997) Postmenopausal vaginal atrophy and atrophic vaginitis. Am J Med Sci 314:228PubMedCrossRefGoogle Scholar
  44. 44.
    Motta P, Makabe S (2003) An atlas of menopausal aging. Parthenon, New York CityGoogle Scholar
  45. 45.
    Ferenczy A (2003) Pathophysiology of endometrial bleeding. Maturitas 45:1PubMedCrossRefGoogle Scholar
  46. 46.
    Gerbaldo D, Ferraiolo A, Croce S et al (1991) Endometrial morphology after 12 months of vaginal oestriol therapy in post-menopausal women. Maturitas 13:269–74PubMedCrossRefGoogle Scholar
  47. 47.
    McGurgan P, Taylor LJ, Duffy SR et al (2006) Does tamoxifen therapy affect the hormone receptor expression and cell proliferation indices of endometrial polyps? An immunohistochemical comparison of endometrial polyps from postmenopausal women exposed and not exposed to tamoxifen. Maturitas 54:252PubMedCrossRefGoogle Scholar
  48. 48.
    Shushan A, Revel A, Rojansky N (2004) How often are endometrial polyps malignant? Gynecol Obstet Invest 58:212–215PubMedCrossRefGoogle Scholar
  49. 49.
    Van Bogaert LJ (1991) Clinicopathologic findings in endometrial polyps. Obstet Gynecol 77:954–956Google Scholar
  50. 50.
    Karlsson B, Granberg S, Wikland M et al (1995) Transvaginal Ultrasonography of the endometrium in women with postmenopausal bleeding – a Nordic multicenter study. Am J Obstet Gynecol 172:1488PubMedCrossRefGoogle Scholar
  51. 51.
    Sylvestre C, Child TJ, Tulandi T et al (2003) A prospective study to evaluate the efficacy of two- and three-dimensional sonohysterography in women with intrauterine lesions. Fertil Steril 79:1222–1225PubMedCrossRefGoogle Scholar
  52. 52.
    Ben-Arie A, Goldchmit C, Laviv Y et al (2004) The malignant potential of endometrial polyps. Eur J Obstet Gynecol Reprod Biol 115:206PubMedCrossRefGoogle Scholar
  53. 53.
    Adams Hillard PJ (2007) Benign Diseases of the Female Reproductive Tract. In: Berek JS (ed) Berek & Novak’s gynecology, 14th edn. Lippincott Williams & Wilkins, Philadelphia, PA, pp 431–504Google Scholar
  54. 54.
    Leibsohn S, d’Ablaing G, Mishell DR Jr et al (1990) Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. Am J Obstet Gynecol 162:968–974PubMedGoogle Scholar
  55. 55.
    Herbst AL (2001) Neoplastic diseases of the uterus. In: Stenchever MA, Droegemuller W, Herbst AL et al (eds) Comprehensive gynecology, 4th edn. Mosby, Inc, St. Louis, MO, pp 921–927Google Scholar
  56. 56.
    Nygaard I, Barber M, Burgio K et al (2008) Prevalence of symptomatic pelvic floor disorders in US women. JAMA 300:1311–1316PubMedCrossRefGoogle Scholar
  57. 57.
    Bump RC, Mattiasson A, Bo K et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:10–17PubMedCrossRefGoogle Scholar
  58. 58.
    Nygaard I, Bradley C, Brandt D (2004) Pelvic organ prolapse in older women: prevalence and risk factors. Obstet Gynecol 104:489–497PubMedCrossRefGoogle Scholar
  59. 59.
    Harris S, Lind C, Tennstedt S et al (2007) Care seeking and treatment for urinary incontinence in a diverse population. J Urol 177:680–684SPubMedCrossRefGoogle Scholar
  60. 60.
    De Lancey JO (1992) Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 166:1717–1724Google Scholar
  61. 61.
    Abrams P, Cardozo L, Fall M et al (2002) The standardization of terminology of lower urinary tract function: Report from the standardization sub-committee of the international continence society. Am J Obstet Gynecol 187:116–126PubMedCrossRefGoogle Scholar
  62. 62.
    Weber AM, Richter HE (2005) Pelvic organ prolapse. Obstet Gynecol 106:615–634PubMedCrossRefGoogle Scholar
  63. 63.
    Sulak PJ, Kuehl TJ, Shull BJ (1993) Vaginal pessaries and their use in pelvic relaxation. J Reprod Med 38:919–923PubMedGoogle Scholar
  64. 64.
    Harris TA, Bent AE (1990) Genital Prolapse with and without urinary incontinence. J Reprod Med 35:792–798PubMedGoogle Scholar
  65. 65.
    Nygaard I, Thom DH, Calhoun EA (2007) Urinary incontinence in women. In: Litwin MS, Saigal CS (eds) Urologic diseases in America. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. US Government Printing Office, Washington, DC, pp 71–103, NIH Publication No. 07–5512Google Scholar
  66. 66.
    Olsen AL, Smith VJ, Bergstrom JO et al (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–506PubMedCrossRefGoogle Scholar
  67. 67.
    Clark AL, Gregory T, Smith VJ et al (2003) Epidemiologic evaluation of reoperation for surgically treated pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 189:1261–1267PubMedCrossRefGoogle Scholar
  68. 68.
    Gerten KA, Markland AD, Lloyd LK, Richter HE (2008) Prolapse and incontinence surgery in older women. J Urol 179:2111–2118PubMedCrossRefGoogle Scholar
  69. 69.
    Carey JM, Leach GE (2003) Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one year results compared to younger patients. Urology 63:665–670CrossRefGoogle Scholar
  70. 70.
    Richter HE, Goode PS, Kenton K et al (2007) The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse. JAGS 55:857–863CrossRefGoogle Scholar
  71. 71.
    Silva WA, Pauls RN, Segal JL et al (2006) Uterosacral ligament vault suspension: five year outcomes. Obstet Gynecol 108:255–263PubMedCrossRefGoogle Scholar
  72. 72.
    Sung VW, Weitzen S, Sokol ER et al (2006) Effect of patient age on increasing morbitity and mortality following urogynecologic surgery. Am J Obstet Gynecol 194:1411–7PubMedCrossRefGoogle Scholar
  73. 73.
    Fitzgerald MP, Richter HE, Bradley CS, et al for the Pelvic Floor Disorders Network. Pelvic support, pelvic symptoms and patient satisfaction after colpocleisis. Intl Urogynecol J 2008;19:1603–1609.Google Scholar
  74. 74.
    Gordon G, Gold R, Pauzner D et al (2005) Tension-free vaginal tape in the elderly: is it a safe procedure? Urology 65:479–482PubMedCrossRefGoogle Scholar
  75. 75.
    Richter HE, Goode PS, Brubaker L et al (2008) Two-year outcomes after surgery for stress incontinence in older compared with younger women. Obstet Gynecol 112:621–629PubMedCrossRefGoogle Scholar
  76. 76.
    Friedman WH, Gallup DG, Burke JJ et al (2006) Outcomes of octogenarians and nonagenarians in elective major gynecologic surgery. Am J Obstet Gynecol 195:547–553PubMedCrossRefGoogle Scholar
  77. 77.
    Madoff RD (2005) Surgery for fecal incontinence in women. In: Abrams P (ed) Incontinence. Health Publications Ltd, France, pp 1585–1588Google Scholar
  78. 78.
    Morse AN, Labin LC, Young SB et al (2004) Exclusion of elderly women from published randomized trials of stress incontinence surgery. Obstet Gynecol 104:498–503PubMedCrossRefGoogle Scholar
  79. 79.
    Eagle KA, Berger PB, Calkins H et al (2002) ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task force on practice guidelines (Committee to update the 1996 guidelines on perioperative cardiovascular evaluation for noncardiac surgery). Circulation 105:1257–1267PubMedCrossRefGoogle Scholar
  80. 80.
    Bitondo Dyer C, Ashton CM, Teasdale TA (1995) Postoperative delirium. Arch Intern Med 155:461–465CrossRefGoogle Scholar
  81. 81.
    Bombeli T, Spahn DR (2004) Updates in perioperative coagulation: physiology and management of thromboembolism and haemorrhage. Br J Anaeth 93:275–87CrossRefGoogle Scholar
  82. 82.
    Kurz A, Sessler DI, Lenhardt R (1996) Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 334:1209–1212PubMedCrossRefGoogle Scholar
  83. 83.
    ACOG Practice Bulletin No.74 (2006) Antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 108:225CrossRefGoogle Scholar
  84. 84.
    Schweitzer KJ, Vierhout ME, Milani AL (2005) Surgery for pelvic organ prolapse in women 80 years of age or older. Acta Obstet Gynecol Scand 84:286–289PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Kimberly A. Gerten
    • 1
  • W. Jerod Greer
  • C. Bryce Bowling
  • Thomas WheelerII
  • Holly E. Richter
  1. 1.Division of Women’s Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and GynecologyUniversity of Alabama at Birmingham Medical CenterBirminghamUSA

Personalised recommendations