Common Gynecological Problems in the Elderly

Report
COMMON GYNECOLOGICAL PROBLEMS IN
THE OLDER WOMAN
MAGGIE H. LEE, MD
GERIATRICS FELLOW
GERIATRICS SPECIALISTS OF LANCASTER
LANCASTER GENERAL HOSPITAL
FEBRUARY 19, 2013
DISCLOSURES
 No commercial or financial disclosures.
LEARNING OBJECTIVES
 Recognize current recommendations for cervical
cancer screening and its cessation
 Summarize differential diagnoses of vulvovaginal
dermatoses and their management

Excluding cancers
 Briefly discuss work-up of postmenopausal bleeding,
focusing on excluding endometrial cancer
CERVICAL CANCER SCREENING
A new 65 year old patient presents to your office to
establish care. She is generally healthy. While
discussing preventative healthcare, she inquires
whether or not she will be getting her Pap smear
done. There is no history of CIN2, CIN3, adenocarcinoma in situ, nor cervical cancer. Her previous
records show normal Pap smears 6 years ago, 8 years
ago, and 9 years ago.
1.
a.
Should she be screened? If so, how often and how?
b.
When can cervical screening stop?
CERVICAL CANCER SCREENING
 New 2012 recommendations!
 21 – 65 yo Pap test alone q 3 years (A)
 30 – 65 yo Pap test WITH HPV q 5 years (A)


Recommends against screening > 65 yo who have had “adequate
prior screening” and are not at high risk for cervical cancer (D)


2.6% chance of normal Pap and (+) HPV in 60 – 65 yo
3 consecutive (-) cytology or 2 consecutive (-) HPV results within last
10 years with most recent test occurring within past 5 years
Can discontinue if >65 yo and no history of CIN2, CIN3,
adenocarcinoma in situ, or cervical cancer and had 3 (-) Paps or 2
(-) HPV results in the last 10 years with most recent test in the last
5 years
National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.
CERVICAL CANCER SCREENING
A new 65 year old patient presents to your office to
establish care. She is generally healthy. While
discussing preventative healthcare, she inquires
whether or not she will be getting her Pap smear
done. There is no history of CIN2, CIN3, adenocarcinoma in situ, nor cervical cancer. Her previous
records show normal Pap smears 6 years ago, 8 years
ago, and 9 years ago.
1.
a.
b.
Should she be screened? If so, how often and how?
Yes. 1 more time with Pap + HPV
When can cervical screening stop?
If the next one is normal, she can stop after that.
CERVICAL CANCER SCREENING
The previous patient returns to your office when she
is 78 years old. Within the past 10 years, she has
been sexually active with 5 different people. She is
HIV negative. If she stopped getting Pap smears at
the age of 66,
2.
a.
Should cervical cancer screening be re-initiated?
CERVICAL CANCER SCREENING
 New 2012 recommendations (continued)

Should NOT resume after cessation of screening in > 65 yo

Patients who have a history of cervical cancer, have HIV, are
immunocompromised, or were exposed to diethylstilbestrol (DES)
in utero should not follow routine screening guidelines.
National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.
CERVICAL CANCER SCREENING
The previous patient returns to your office when she
is 78 years old. Within the past 10 years, she has
been sexually active with 5 different people. She is
HIV negative. If she stopped getting Pap smears at
the age of 66,
2.
a.
Should cervical cancer screening be re-initiated?
Not needed.
CERVICAL CANCER SCREENING
A 68 year old postmenopausal woman comes to your
office requesting her annual Pap Smear. She had a
colposcopy with biopsies done at the age of 52 and a
Loop Electrosurgical Excision Procedure done at the
age of 53. She was told she had “cancer but they got
it all, but needs yearly testing.”
3.
a.
How often should she be tested?
b.
How should she be tested?
c.
When can cervical cancer screening be stopped assuming
subsequent testing is normal?
CERVICAL CANCER SCREENING
 New 2012 recommendations (continued)

Routing screening should continue x 20 years after spontaneous
regression/management of high-grade precancerous lesions
National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.
CERVICAL CANCER SCREENING
A 68 year old postmenopausal woman comes to your
office requesting her annual Pap Smear. She had a
colposcopy with biopsies done at the age of 52 and a
Loop Electrosurgical Excision Procedure done at the
age of 53. She was told she had “cancer but they got
it all, but needs yearly testing.”
3.
a.
b.
c.
How often should she be tested?
At least every 3 years
How should she be tested?
Pap q 3 years OR PAP+HPV-HR every 5 years
When can cervical cancer screening be stopped assuming
subsequent testing is normal? At the age of 53+20 = 73
CERVICAL CANCER SCREENING
4.
What if the patient’s next routine screening results
showed ASCUS with negative HPV-HR?
5.
What if the patient’s next routine screening results
showed normal Pap with positive HPV-HR?
CERVICAL CANCER SCREENING
 New 2012 recommendations (continued)
 Co-testing should NOT be performed in those < 30 yo.
 For those 30+ yo:
(+)HPV and (-) Pap
or
Genotype for
HPV 16+18
pos
Repeat co-testing
in 12 months
neg
Not
neg
-/colposcopy
Back to routine
screening
NOTE: ASCUS with (-)HPV should
return to routine screening
National Guideline Clearinghouse, USPSTF, ACS, ASCCP, ACOG; Ob & Gyn; 2012, 120(5): 1222 – 1238.
(cont’d)
VULVOVAGINAL DERMATOSES
A 69 year old patient, who has had UTIs at least every
year for the past 5 years, comes to the office because
she has vulvar burning, itching, and soreness. She
does not complain of discharge. However, on
preliminary examination, there is slight introital
stenosis, loss of vaginal rugae, flattening of the labia
architecture, slight urethral telescoping, and a slight
yellow vaginal discharge.

What do you do next?

Do you have a final diagnosis?
Modified from Geriatrics Review Syllabus. 7th edition.
VULVOVAGINAL DISCHARGE
Normal
Bacterial Vaginosis
Trichomonas
Vaginitis
Candidal Vaginitis
Symptoms
Possible
discharge
Itching, malodorous
discharge
Itching, dysuria,
excessive discharge
Itching, discharge
Vaginal pH
3.5 – 4.2
> 4.5
> 4.5
< 4.5
Discharge
White,
heterogeneous
Thin, homogeneous,
gray, white/grey
Yellow, green, frothy,
adherent
Cottage cheesy, curd-like
Whiff test
Negative
Positive
Positive
Negative
Wet prep
Lactobacilli,
plump
epithelial cells
Clue cells
No WBCs
Trichomonas, WBCs
> 10/hpf
Hyphae, pseudohyphae,
spores
1.
Treatment
None
2.
Metronidazole
gel 5g QHS x 5
days or 500mg
PO BID x 7 days
or
clindamycin
300 mg BID x 7
days
1.
2.
Metronidazole 2
g PO x 1 or
50mg PO BID x
7 days
or
Clindamycin 1g
intravaginally x
7 days
1.
2.
Fluconazole 150mg
PO x 1 or Nystatin
for C. albicans
or
Intravaginal boric
acid tabs 600mg
daily x 2-3 weeks
for non-C. albicans
VULVOVAGINAL DISCHARGE
Normal
Bacterial Vaginosis
Trichomonas
Vaginitis
Candidal Vaginitis
Vulvovaginal
Atrophy
Symptoms
Possible
discharge
Itching, malodorous
discharge
Itching, dysuria,
excessive discharge
Itching, discharge
See algorithm
Vaginal pH
3.5 – 4.2
> 4.5
> 4.5
< 4.5
Discharge
White,
heterogeneous
Thin, homogeneous,
white/grey
Yellow, green, frothy,
adherent
Cottage cheesy, curd-like
Whiff test
Negative
Positive
Positive
Negative
Wet prep
Lactobacilli,
plump
epithelial cells
Clue cells
No WBCs
Trichomonas, WBCs
> 10/hpf
Hyphae, pseudohyphae,
spores
1.
Treatment
None
2.
Metronidazole
gel 5g QHS x 5
days or 500mg
PO BID x 7 days
or
clindamycin
300 mg BID x 7
days
1.
2.
Metronidazole 2
g PO x 1 or
50mg PO BID x
7 days
or
Clindamycin 1g
intravaginally x
7 days
1.
2.
Fluconazole 150mg
PO x 1 or Nystatin
for C. albicans
or
Intravaginal boric
acid tabs 600mg
daily x 2-3 weeks
for non-C. albicans
Topical hormonal
therapy
3x/week:
1. Premarin
cream
2. 10-25 mcg
Vagifem tablets
3. Estring
PHYSIOLOGY
 Menopause:
 Urogenital:  blood flow,  tissue oxygenation
Workflow of pH paper use for confirming
Vulvovaginal Atrophy at GSL and WLAFHC
Patient > 65 yo or menopausal
(naturally or surgically)?
No
Yes
No further
action
Complains
of…
None of the
symptoms
listed to the
right
> 1 of following symptoms:
• h/o recurrent • urinary
UTI with
incontinence
• urinary
frequency OR
• urinary
urgency OR
and
• dysuria
1. Place pH strip in middle
vagina on lateral wall for 5
seconds prior to urination.
2. Obtain U/A
• dyspareunia
• vaginal
dryness
• vaginal
discharge
• encounter for
Pap/gyn exam
1. Have patient changed into gown for
pelvic exam.
2. Place pH strip in middle vagina on
lateral wall for 5 seconds
3. Perform wet prep if indicated.
4. Perform whiff test if + discharge.
VULVOVAGINAL DISCHARGE
Normal
Bacterial Vaginosis
Trichomonas
Vaginitis
Candidal Vaginitis
Vulvovaginal
Atrophy
Symptoms
Possible
discharge
Itching, malodorous
discharge
Itching, dysuria,
excessive discharge
Itching, discharge
See algorithm
Vaginal pH
3.5 – 4.2
> 4.5
> 4.5
< 4.5
>5
Discharge
White,
heterogeneous
Thin, homogeneous,
white/grey
Yellow, green, frothy,
adherent
Cottage cheesy, curd-like
May not have any
Whiff test
Negative
Positive
Positive
Negative
Negative
Wet prep
Lactobacilli,
plump
epithelial cells
Clue cells
No WBCs
Trichomonas, WBCs
> 10/hpf
Hyphae, pseudohyphae,
spores
Smaller size and
shape of epithelial
cells, minimal
lactobacilli
1.
Treatment
None
2.
Metronidazole
gel 5g QHS x 5
days or 500mg
PO BID x 7 days
or
clindamycin
300 mg BID x 7
days
1.
2.
Metronidazole 2
g PO x 1 or
50mg PO BID x
7 days
or
Clindamycin 1g
intravaginally x
7 days
1.
2.
Fluconazole 150mg
PO x 1 or Nystatin
for C. albicans
or
Intravaginal boric
acid tabs 600mg
daily x 2-3 weeks
for non-C. albicans
Topical hormonal
therapy
3x/week:
1. Premarin
cream
2. 10-25 mcg
Vagifem tablets
3. Estring
VULVOVAGINAL DERMATOSES
A 69 year old patient, who has had UTIs at least every
year for the past 5 years, comes to the office because
she has vulvar burning, itching, and soreness. She
does not complain of discharge. However, on
preliminary examination, there is slight introital
stenosis, loss of vaginal rugae, flattening of the labia
architecture, slight urethral telescoping, and a slight
yellow vaginal discharge.


What do you do next?
Analyze the vaginal discharge, diagnose vaginal atrophy.
Do you have a final diagnosis?
Possibly...
Modified from Geriatrics Review Syllabus. 7th edition.
VULVOVAGINAL DERMATOSES
On further examination, there is evidence of vulvar
scarring, glassy erythematous erosions, white striae
along the margins of the labia minora an vestibule, and
vaginal involvement. A specimen is obtained for
biopsy. Which of the following is the most likely
diagnosis?
Vulvar Dermatitis
 Lichen sclerosus

Geriatrics Review Syllabus. 7th edition.
Lichen simplex chronicus
 Lichen planus

BASIC DIFFERENTIAL
Age
Risk
Factors
Symptoms
Vulvar
Dermatitis
Lichen Simplex
Chronicus
Lichen
Sclerosus
Lichen Planus
(Erosive Type)
Any
Any
Peak incidence prepubertal/
Postmenopausal (1 in 30)
Peak incidence in 30 – 60 yo
Atopy, Incontinence,
 Estrogen
Chronic
scratching/rubbing
Autoimmune (thyroid, alopecia,
vitiligo);  estrogen
Autoimmune?
Itching >>
burning/pain
Itching, irritation!
Itching >> soreness, burning,
pain, dysuria, defecation pain
Soreness > itching >
dyspareunia, + yellow discharge
Lichenification
Lichenification
Remove
irritants/allergens;
Short term potent
steroid ointment then
mild x 2 – 3 months
Mild – moderate steroids
BID until pruritus
resolves then decrease
steroid freq/strength
NO vaginal involvement;
NOT mucosal; extragenital
involvement
+ reticulate lace pattern;
Erosions on MUCOSAL
surfaces; red
Key
Features
Treatment
No cure; Vulvar hygiene; Super
potent steroid ointments or
immunosuppressants;
< 5% transform to vulval SCC
Super potent steroid ointments
or immunosuppressants;
Unconfirmed risk of
invasive SCC
VULVOVAGINAL DERMATOSES
On further examination, there is evidence of vulvar
scarring, glassy erythematous erosions, white striae
along the margins of the labia minora an vestibule, and
vaginal involvement. A specimen is obtained for
biopsy. Which of the following is the most likely
diagnosis?
Vulvar Dermatitis
 Lichen sclerosus

Geriatrics Review Syllabus. 7th edition.
Lichen simplex chronicus
 Lichen planus

EXTENDED DIFFERENTIAL
VIN
(Differentiated
Type)
Paget’s
Disease
Desquamative
Inflammatory
Vaginitis
Pemphigus
Vulgaris
Age
Mainly older women
Usually 60 – 70 yo
Pre/post menopausal
50 – 60 yo seen most often
Symptoms
Itching >>> burning,
pain, lump, edema,
dyspareunia
Itching, >> burning/pain
Irritation, burning, dyspareunia
+ purulent vaginal discharge
Pain
Smoking
Chronic scratching/rubbing
 Estrogen
Autoimmune
Macroscopically visible
lesion; Raised red/white
+ pigmented lesion
Well-demarcated
erythematous patch with
white hyperkeratotic area;
eczematous, red, weeping
Erythematous vaginal walls;
introital redness + extension to
labia minor with swelling;
NO vulvar involvement
Blisters of keratinized skin;
well-demarcated ulcers of
mucosal skin
Risk
Factors
Key
Features
BIOPSYING TIPS
 Adequate anesthesia: 2% lidocaine with epi
 Biopsy primary lesions
 Have a differential in mind or the pathology may not help
 Thick/raised area  get thickest area, 4 mm punch
 Erosions/scarring  look for fresh non-traumatized skin and
may want to get viral cultures
 Blister  biopsy NEXT to it
 Ulcer/erosion  4 mm punch at leading edge and around
 If multiple biopsies, start at the bottom and move up.
 Multiple biopsies for multifocal disease
TREATMENT
 Vulvar hygiene
 Super potent steroid then decrease to mild potent
steroid for maintenance

“Rule of Two’s”
Clobetasol 0.5% ointment BID x 2 months
 Then QHS x 2 months
 Then PRN x 2 weeks at a time for flares and place on maintenance
mid potency 0.025 – 0.1% triamcinolone cream


How big of a tube?
Finger Tip Unit = 2 handprint’s ~ 0.5 g
 45 g of 2 months BID should last 2 – 12 months

 Schedule return visits in 1 – 2 months
STEROID COMPLICATIONS to AVOID
 Suppression of hypothalamic pituitary adrenal axis:
 Continuous topical application of 90g/month of superpotent
steroid can
 Osteopenia
 Cataracts
 Rebound dermatitis
 Candida superinfection
 2% ketoconzole lotion or cream
 Diflucan 150mg weekly x 2 – 4 months then monthly at least 4
months
WHEN TO REFER
 Not healing with steroids
 Correct diagnosis?
 Poor symptom control
 > 30g/6 months or use > 3x/week
 Presence of irregular white plaques, erosions, ulcers,
and NO atrophy
 Previously treated for VIN/vulvar SCC
 Localized skin thickening/hyperkeratosis
 Biopsies where differentiated VIN possible
POSTMENOPAUSAL BLEEDING
Which of the following is the most likely cause of new onset
vaginal bleeding in a 70 year old woman?
Endometrial cancer
 Endometrial hyperplasia
 Pyometria
 Vaginal atrophy
 Hormonal effect

GRS. 7th edition.
Cause of bleeding
%
Atrophy
59%
Polyp
12%
Endometrial cancer and hyperplasia
~10%
Hormonal effect
7%
Cervical cancer
<1%
ENDOMETRIAL CANCER
 4th most common cancer in women in U.S.
 90% occur in > 50 yo
Risk Factor
 95% Type 1 associated with estrogen High cumulative doses of tamoxifen
exposure  endometrial hyperplasia Estrogen-producing tumor
WHO cytology
classification system

% change to
carcinoma
Simple without atypia
1%
Simple with atypia
8%
Complex without atypia
3%
Complex with atypia
29%
5% Type 2 not associated with
estrogen exposure
Obesity
BMI 30 – 34
BMI 35 – 39
BMI > 40
Nulliparity
DM2, HTN, thyroid, or gallbladder
disease
Relative
Risk
3–7
>5
1.7
4.3
6.4
3
1.3 – 3
Older age
2–3
History of infertility
2–3
Menopause at > 52 yo
2–3
Menstrual irregularities
Age at menarche (< 12 yo)
Long term use of high dosages of
OCPs, Smoking
1.5
1.5 – 2
0.3 – 0.5
ENDOMETRIAL CANCER
 No benefit in screening
 unless risk for HNPCC
 History & Physical
 BMI, pelvic exam (uterus size)
 Bloodwork
 Urine preg
 Rule out STDs
 CBC, TSH, LFTS
 PTT/INR, vWF
 Pap?
 Pap:
 “benign endometrial cells”
 further eval
 No Level A approach
from ACOG
ENDOMETRIAL CANCER
or
or
or
POSTMENOPAUSAL BLEEDING
 ACOG Committee Opinion 8/2009
 Women with postmenopausal uterine bleeding may be assessed
initially with either endometrial biopsy or transvaginal
ultrasonography; this initial evaluation does not require
performance of both tests,
 If tissue from endometrial biopsy is insufficient for diagnosis,
further investigation is necessary and TVUS may be performed.
 IF TVUS is performed, and an endometrial thickness of < 4 mm is
found, endometrial sampling is not required.
 The significance of an endometrial thickness of >4 mm in an
asymptomatic, postmenopausal patient has not been established.
APPENDIX
 References
 Geriatric Pelvic Exam Tips
 Vulvar Dermatitis: Common irritants and allergens
 Vulval Hygiene
 Topical Steroids: Potency Chart
 Topical Steroid Cross-Reactivity
 Sensitivity and Specificity of Vaginal Discharge/Tests
 Candidal Vaginitis
 Vulvovaginal Atrophy
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
American Geriatrics Society. (2010). Gynecologic diseases and disorders. In Pacala JT and Sullivan GM (Eds.) Geriatrics Review
Syllabus 7th edition. 468–73. New York.
Beecker J. Therapeutic principles in vulvovaginal dermatology. Dermatol Clin, 2010. 28: 639–48.
Biggs WS and Williams RM. Common gynecologic infections. Prim Care Clin Office Pract, 2009. 36: 33–51.
Buchanan EM et al. Endometrial cancer. AAFP, 2009. 80(10): 1075 – 80.
Carter JS and Downs, Jr LS. Vulvar and vaginal cancer. Ob Gyn Clin N Am, 2012. 39: 213–31.
Edwards L. Dermatologic causes of vaginitis: a clinical review. Dermatol Clin, 2010. 28: 727–35.
Gerten KA et al. Benign gynecologic disorders in the older woman. In Rosenthal RA et al. (Eds.) Principles and Practice of
Geriatric Surgery 2nd edition. 1083–97. New York.
Lentz SS and Homesley HD. Gynecologic problems in older women. Clinics Geri Med, 1998. 14(2): 297–315.
McKay M. Vulvar disease. 56th T. Har Baker, MD, Obstetrcis and Gyencology Symposium. Audio Digest, 2012: 59(23).
Mehta A and Bachmann G. Vulvovaginal complaints. Clin Ob Gyn, 2008. 51(3): 549–55.
Moroney JW and Zahn CM. Common gynecologic problems in geriatric-aged women. Clin Ob Gyn, 2007. 50(3): 687–708.
Pastore LM et al. Vaginal symptoms and urinary incontinence in elderly women. Geriatrics, 2007. 62(7): 12–18.
Policar MS. Office gynecology: Managing common concerns in women. 2011 UCSF Family Medicine Board Review. Audio Digest,
2012. 60(10).
Olsson A et al. Postmenopausal vulval disease. Menopause Int, 2008. 14(4): 169–72.
Quan M. Vaginitis: diagnosis and management. Postgrad Med, 2010. 122(6): 117–27.
Saunders NA and Kaefner HK. Vulvar lichen sclerosus in the elderly. Drugs Aging, 2009. 26(1): 803–12.
Practice Bulletin: Screening for Cervical Cancer. Obst & Gyn, 2012. 120(5): 1222 - 1238.
Schorge JO et al. Abnormal uterine bleeding. In Williams Gynecology 1st and 2nd edition. New York.
Stiles M et al. Gynecologic issues in geriatric women. J Wom Health, 2012. 21(1): 4–9.
Torres MR and Canto G. Hypersensitivity reactions to corticosteroids. Curr Opin Allergy Clin Immunol, 2010. 10(273).
GERIATRIC PELVIC EXAM TIPS
 Performing pelvic exam:
 Narrow-blade speculum
 Use 1 finger for bimanual
 Frog-leg position
+ inverted bedpan covered by towel
 Use speculum upside down


Left lateral decubitus position, assistant holds right leg up
 If with introital/cervical stenosis, topical
estrogen x 1 – 2 weeks prior to speculum exam
 May use cytobrush or dilators/sounds to help dilate
cervix prior to endometrial biopsy
Vulvar Dermatitis
Common
irritants
Example(s)
Common contact allergens
Physical
irritants
Excessive washing, wash cloths, hair
dryers, sanitary pads, tight clothing
Topical anesthetics
(eg benzocaine)
Chlorhexidine
(in K-Y jelly)
Hygiene
products
Soaps and cleansers, powders,
douches, perfumes, deodorants,
bubble bath/oils/salts, depilatory
creams, adult/baby wipes
Perfumes
Latex
Body fluids
Sweat, vaginal secretions, urine,
feces, semen
Preservatives
(i.e. in [Rx] creams,
hygiene products)
Topical
antifungal
medications
Topical antibiotics
(i.e. neomycin)
Topical
steroids
Medications
Antifungal/OTC anti-itch creams,
topical antibacterial agents
Lubricants and
contraceptives
Spermicides, condoms, diaphragms,
lubricants
Vulval Hygiene
Avoid
Substitute
Pantyhose
Stockings with a garter belt; Thigh high or knee high stockings
Synthetic underwear
Cotton underwear or no underwear
Jeans and other tight pants
Loose pants, skirts, dresses; loose-fitting cotton garments
Pantyliners
Cotton pads
Scented soaps or shampoos
Fragrance free pH neutral soap (eg Basis, Neutrogena, Dove)
Bubble bath
Tub baths in the morning and at night without additives and
at a comfortable temperature
Scented detergents
Unscented detergents
Washcloths
Use fingertips for washing; pat dry, don’t rub dry
Feminine sprays, douches, powders
Omit from personal practice
Dyed toilet articles
Toilet articles without dyes
Hair dryers to dry vulva skin without contact
Dry vulva by gentle patting
Topical Steroids: Potency Chart
Potency
Class
1
Super
Potent
2
Potent
3
Upper Mid
Generic Names
Strengths (%)
Betamethasone dipropionate (oint)
0.05
Clobetasol propionate (cream/lotion/oint/soln)
0.05
Diflorasone diacetate (oint)
0.05
Fluocinonide (cream)
0.1
Halobetasol propionate (cream/oint)
0.05
Betamethasone dipropionate (cream)
0.05
Desoximetasone (cream/oint)
0.25
Diflorasone diacetate (cream/oint)
0.05
Fluocinonide (cream/oint)
0.05
Halcinonide (cream/oint)
0.1
Mometasone furoate (oint)
0.1
Desoximetasone (cream)
0.05
Fluocinonide (cream)
0.05
Fluticasone propionate (oint)
0.005
Adapted from www.psoriasis.org
Topical Steroids: Potency Chart
Potency
Class
Generic Names
(cont’d)
Strengths (%)
Fluocinolone acetonide (oint)
0.03
Flurandrenolide (cream)
0.05
Hydrocortisone valerate (oint)
0.2
Mometasone furoate (cream)
0.1
Triamcinolone acetonide (oint)
0.03
Desonide (lotion)
0.05
Flurandrenolide (cream/lotion/tape)
0.05
Fluticasone propionate (cream/lotion)
0.05
Hydrocortisone (cream/lotion/oint/soln)
0.1
Hydrocortisone valerate (cream)
0.2
Prednicarbate (cream)
0.1
6
Mild
Alclometasone dipropionate (cream/oint)
0.05
Fluocinolone acetonide (cream/oil/soln)
0.01
7 Least
Hydrocortisone (cream/lotion/oint/spray)
0.5 / 1 / 2 / 2.5
4
Mid
5
Lower Mid
Adapted from www.psoriasis.org
Topical Steroid Cross-Reactivity
Class
Example
A
Hydrocortisone type without
substitution on the D-ring or C17
carbon chain, but including C17
and/or C21 acetate esters
Hydrocortisone (acetate, phosphate, succinate)
Methylprednisolone (acetate, phosphate, succinate)
Prednisolone
Tixocortol pivalate
Triamcinolone acetonide type
C16, C17-cis, diol, or ketal chain
Amcinonide
Budesonide
Desonide
Flunisolide
Fluocinolone acetonide
Fluocinomide
Halcinonide
Triamcinolone
Betamethasone type C16 alkyl
substitution
Betamethasone
Desoxymethasone
Dexamethasone
Paramethasone
Flucortolone
Hydrocortisone-17-butyrate
type C17 and/or C21 long-chain
ester
Beclomethasone (diproprionate, valerate)
Clobethasone (butyrate, propionate)
Fluticasone
Mometasone
Prednicarbate
Hydrocortisone (butyrate, propionate)
Methylprednisolone aceponate
B
C
D
Adapted from: Torres MJ and Canto G.
Glucorticoid
Structure
Sensitivity and Specificity
of Vaginal Discharge/Tests
Bacterial Vaginosis
Vulvovaginal Candidiasis
Trichomonas
Test
Sensitivity
Specificity
Saline mount
62%
97%
Pap smear
57%
97%
Culture
95%
> 95%
Rapid antigen
88%
99%
Candidal Vaginitis

Refractory cases:
Fluconazole 150mg x 3 q 72 hours
 Topical azole therapy for 1 – 2 weeks


Recurrent cases (> 4 symptomatic cases /yr)
Fluconazole 150mg x 3 q 72 hours then weekly
 May also use itraconazole or terbinafine

 Prophylaxis:
 If starting estrogen,
Fluconazole 150mg PO q week x 5 weeks
 Nystatin ointment compounded in estrogen
 Azole cream compounded in estrogen


If starting on antibiotics
or
or
Vulvovaginal Atrophy
 Treatment
 Hormonal 3x/week

Topical estrogen >> systemic
 10 – 25% women will continue to experience symptoms with
systemic estrogen
 Vaginal Ring: Estring
 Vagifem tablets: 10 or 25 mcg nightly
 Estrace/Premarin Cream: 1 g

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