Office management of the gynecologic problems of elderly female patients requires sensitivity to the special needs of this group. The general gynecologist can expect to see more geriatric women as the U.S. population continues to age. In 1990, 12.6% of the population was older than 65 years of age. By the year 2050, this figure will almost double to 22.9%, or 100 million elderly.¹ These changing demographics raise the problem of providing gynecologic care for these women and the issue of the role of gynecologist as their primary care physician. This chapter addresses both areas in sections on screening and disease prevention and on management of gynecologic problems in this age group.

What should be the role of the gynecologist in screening elderly women for disease? The answer depends on the clinical situation in which the patient presents. Ideally, disease prevention and screening should be done at regular visits to a primary care physician. Last defined primary care as “continuity of care and ongoing relationship between patient and physician, superseding issues of medical specialty, to provide for health maintenance and disease prevention.”² An otherwise healthy woman whose obstetrician or gynecologist is her only physician has needs that are different from those of the patient with comprehensive geriatric care who is being referred for a specific complaint. Many aspects of gynecologic and medical screening may not be addressed by the patient's primary care provider. For example, 14% of women between the ages of 65 and 74 years and 39% of those older than 75 have never had a Papanicolaou (Pap) smear.³ Gynecologists can ensure with annual examinations that this type of basic health maintenance screening is not overlooked.

Primary care stresses counseling on healthy lifestyles, avoidance of risks, and early disease detection. Periodic examinations should concentrate on conditions that cause morbidity and mortality, are detectable when asymptomatic, and have better treatment outcomes with early detection. The physician should assess the status of chronic illnesses. Polypharmacy is an iatrogenic problem that affects many of the elderly. Adverse drug reactions are responsible for many of this group's hospital admissions,⁴ and the more medications the patient is taking, the more likely is an adverse reaction.⁵ The annual checkup can be an opportunity to review continuing need for all prescription drugs, and also to ask about over the counter and herbal remedies that the patient may not mention. Typical problem medications are psychotropics, antihypertensives, digoxin, nonsteroidal antiinflammatory drugs, steroid preparations, theophylline, and warfarin.

The elderly woman's diet and level of physical activity can significantly affect her health. Nutritional status can be affected by slowing metabolic rate, loss of dentition, loss of smell and taste receptors, and the effects of poverty, isolation, and depression. Aging typically is associated with a decrease in lean body mass and a corresponding increase in the percent of body fat; however, these changes may be the result of inactivity. The practitioner should encourage physical activity tailored to the patient's medical problems and level of fitness. Exercise has been shown to improve cardiopulmonary and muscular fitness in the elderly⁶ and preserve functional capacity. It can benefit glucose control, prevent osteoporosis, and benefit preservation of cognitive function, possibly through increased oxygen transport.

Visits should also present opportunities for review of vaccinations and assessment of activities of daily living (ADLs), social supports, and substance abuse screening. Social vulnerability, economic problems, and psychiatric illnesses put older patients at risk. Asking patients about tobacco, alcohol, and prescription medication abuse is important because these problems are not rare and can be treated. For example, studies⁷ suggest that 10% to 15% of women older than 65 years of age abuse alcohol. Structured interviews such as Michigan Alcohol Screening Test (MAST) and CAGE (for ‘cut down, annoyed by criticism, guilty about drinking, eye-opener drinks”) are reliable screening instruments. Women are more likely to be prescribed psychoactive medication,⁷ especially in the institutional setting. Cigarette smoking carries a relative mortality risk of 1.8 for women age 65 and older in the National Institute on Aging Epese study.⁸ Quitting appears to decrease mortality within 1 to 2 years. This visit is also an opportunity to screen for common mental disorders such as depression, anxiety, and sleep disorders, all of which are more common in elderly women than in elderly men.⁹

Screening for gynecologic and nongynecologic cancer is a critical part of annual checkups. Fifty percent of all malignancies occur in the 11% of the population older than 65 years of age.^10,11 When does early detection improve morbidity, mortality, and quality of life for the elderly? An effective strategy requires common diseases with an early symptomatic period, significant burden of disease, an accurate and low-risk screening test, and the availability of effective and acceptable treatment.¹² Based on these criteria, screening for breast, colon, cervical, and endometrial (by evaluation of any bleeding) cancer makes sense in this population. These issues are well addressed elsewhere; Table 1 offers suggested screening protocols.¹²

TABLE 1. Age 65 and Older: Interventions Considered and Recommended for the Periodic Health Examination*

In addition to the evaluations listed in the guidelines, special attention should be paid to issues that the gynecologist is uniquely qualified to address. The Department of Health and Human Services Clinical Practice Guidelines stress that all patients be screened and offered treatment for urinary incontinence.¹³ It is important to routinely ask about this condition. Other problems such as atrophic and infectious vaginal urinary frequency and sexual dysfunction can follow from the urogenital effects of menopause.

About 190 surgical procedures per 100,000 persons older than 65 are performed annually. The medical problems of the elderly affect surgical treatment of their gynecologic problems. A trend toward higher surgical mortality in the elderly observed during the 1960s and 1970s has been attributed to more older and sicker patients being taken to the operating room than ever before.^14–16 Sikes and Det-mer reported 10.8% mortality rate for patients between the ages of 90 and 94.¹⁷ Weighing the risk versus the benefit is critical,¹⁶ especially for elective surgery. Eighty percent of those older than 65 have a chronic illness, and 35% of these have more than three problems; general health is an important area for the gynecologist to assess before surgery.

There is no specific risk assessment for gynecologic and urogynecologic surgery. Few data exist on the risks of these procedures compared with general surgical procedures. The overall mortality rate for gynecologic surgery in the aged is 0.6%, according to an older study.¹⁵ Sultana and colleagues¹⁸ found incontinence procedures to have a mortality rate of only 0.33% for patients older than 64 years of age. Most deaths and complications were related to coronary artery disease and embolism. Death rates increased after age 80. Elderly patients undergoing surgery for gynecologic malignancy are at no greater risk than their younger counterparts.¹⁹ In general, the physician should evaluate medical and surgical history, assess all medications, and conduct a thorough review of systems. Prophylaxis for venous thrombosis should be planned.

Two rating scales are in common use in preoperative evaluation. The Goldman Multifactorial Cardiac Risk Index was developed after a study of 1001 patients older than 40 on general surgical services.²⁰ Nine factors were associated with life-threatening or fatal complications (Table 2). A point score greater than 26 carries a 22% chance of life-threatening complications and a 56% chance of death. The American Society of Anesthesiologists (ASA) scale is a clinical measure that correlates with arterial blood gas, pulmonary capillary wedge pressures, and right heart catheterization in predicting mortality²¹ (Table 3). Cardiac complications peak 3 to 5 days postoperatively.

TABLE 2. Goldman Multifactorial Index of Cardiac Risk in Noncardiac Surgical Procedures

TABLE 3. American Society of Anesthesiologists Physical Status Scale

  Class 1: A normal, healthy person
  Class 2: A patient with mild systemic disease
  Class 3: A patient with severe systemic disease that is not incapacitating
  Class 4: A patient with incapacitating systemic disease that is a constant threat to life
  Class 5: A moribund patient who is not expected to survive 24 hours with or without operation

General nutritional status can be assessed by albumin level and total lymphocyte count. This is important for wound healing and in planning postoperative nutrition when patients must depend on parenteral feeding for prolonged periods. Discharge planning to the patient's home, that of a family member, or to a nursing home or extended care facility needs to be discussed preoperatively. A team approach that takes into account the effect of surgery on the patient's ADLs works best.

A useful approach to evaluating medical concerns before surgery is by organ system. Neurologic functioning, especially in terms of ADLs, is important, because most patients lose ground with prolonged hospitalizations. Many studies^22,23 have looked at whether Acute Care of the Elderly units can avoid this complication. Functioning is related to the patient's baseline cognitive state. Dementia is a symptom complex that affects 5% of those older than 65 and 20% of those older than 80. It is defined as a deterioration of cognitive functions sufficient to interfere with the activities of daily living. Fifteen percent of cases have reversible causes. Dementia is an independent risk factor for surgical mortality, which is as high as 45% in some studies.²⁴ Dementia must be distinguished from postoperative delirium, which occurs in 10% to 15% of cases and can be caused by infection, drug toxicity, intensive care unit psychosis, and metabolic derangement.

The elderly are vulnerable to cardiac death because of age-associated decreases in myocardial contractility and inotropic response. A decrease in the maximum achievable heart rate and an increase in vascular resistance result in a decreased maximum cardiac output. Cardiac status has been extensively studied for prediction of mortality and postoperative complications. Simple tests such as chest radiographs can predict left ventricular dysfunction by identifying cardiomegaly and pulmonary edema.^25,26 An electrocardiogram with asymptomatic sinus bradycardia or bundle branch block requires no further evaluation, but evidence of premature ventricular contractions, atrial fibrillation, or T-wave inversion does. The treadmill test has not been well defined as a predictor of postoperative complications,²⁷ although some investigators recommend it.²⁸ For patients with a recent history of infarction, the rate of reinfarction decreases to 5% after 6 months, and surgery therefore should be delayed. Patients with coronary artery disease who undergo cardiac bypass before elective surgery have decreased mortality compared with those who do not (0.9% versus 2.4%).²⁹ Asymptomatic carotid bruits do not need evaluation before surgery, and most systolic murmurs are insignificant. However, any findings that suggest aortic stenosis mandate investigation, because stenotic or regurgitant lesions of the mitral or aortic valves are associated with a 20% risk of heart failure postoperatively. Hypertension in and of itself is not associated with increased surgical risk. Goldman found no correlation between preoperative blood pressures less than 170/110 mm Hg and the incidence of postoperative arrhythmias, ischemia, heart failure, or renal failure.³⁰ There appears to be no association between hypertension and complications in patients having incontinence procedures.¹⁸

With aging, there is a linear increase in functional residual capacity and decreased vital capacity. Sensitive indicators of potential pulmonary problems are a maximum breathing capacity less than 50% predicted and a forced expiratory volume in 1 second (FEV₁) of less than 2 L. Hypercapnia is a better predictor than hypoxia, but in general the age-adjusted PaO2 should equal 100 - (1/3 age in years). The risk of postoperative pneumonia in elderly patients may be as high as 17%.³¹ Underlying asthma, chronic obstructive pulmonary disease, and cigarette smoking increase the chance of pulmonary complication, as does upper abdominal surgery. Lower abdominal surgery has less impact on ventilation, and vaginal surgery has the least. The most common time for pulmonary edema is 36 to 48 hours postoperatively, when fluid mobilization begins. The kidneys undergo a decrease in renal mass and glomeruli with aging. Concentrating ability is lessened. The decrease in glomerular filtration rate can be masked by decreased muscle mass and a corresponding drop in serum creatinine. Creatinine clearance remains the best indicator of renal function in the elderly, but a blood urea nitrogen level over 50 mg/dl and a serum creatinine level over 3 mg/dl are also signs of poor renal function.

Patients with diabetes suffer from poor tissue repair and compromised leukocyte function. For type I insulin-dependent diabetic patients, the intraoperative blood glucose level should be kept at 250 mg/dl, and a continuous insulin infusion should be used if needed to keep levels in the postoperative period between 70 and 140 mg/dl. Type II diabetics should be closely observed but may not need their oral agents restarted until they are ready for discharge and back on their usual diets.

The types of problems that women in this age group develop depend to some degree on whether they are using hormone replacement therapy (HRT). When postmenopausal patients complain of increased vaginal discharge without itching, physicians should be aware that this may represent improved vaginal lubrication that some women interpret as infection. However, estrogen replacement can also cause some women to be susceptible to yeast infections again. Older women can still contract sexually associated vaginitis; a thorough sexual history can help identify a woman at risk. Vulvar dystrophy and dysplasia can present with itching, as can malignancies of the vulva. Physicians should have a low threshold for performing a biopsy of any red, white, or ulcerated lesion on the vulva. If these causes have been excluded, older women with vulvovaginal discomfort or dyspareunia should be evaluated for vulvodynia, vulvar vestibulitis, simple atrophic vaginitis that responds to HRT, and desquamative vaginitis. The latter is a painful condition whose cause is unknown. It is characterized by a severely reddened mucosa with alkaline pH and seems to respond to clindamycin creams.

Pain and bleeding around the urethra can be the result of a urethral caruncle, which is treatable with estrogen creams. Caruncles that do not resolve need a biopsy to exclude transitional cell carcinomas. Other vulvar problems that increase with age are seborrheic keratoses, senile hemangiomas, papillary hidradenoma, and Bartholin's cysts.

Sexuality in the woman older than 65 deserves to be part of a routine review of systems. Sexual dysfunction is commonly attributed to physical changes associated with the climacteric and emotional issues associated with this life event. The negative psychosocial connotations of aging and emphasis on youth as a prerequisite for sexuality in our society can also exert effects on patient's self-perceptions and beliefs about what is “normal” and expected at this time in the life cycle. The current generation of elderly women does seem to lose some interest in sex or to be less distressed than their male counterparts about medical problems that interfere with sexuality.³² In a study done at Duke in the 1960s,³³ 50% of the women older than 65 surveyed had no interest in sexual activity. However, the elderly are not a homogenous group when it comes to sexual functioning, and the physician must be aware of cohort bias in this type of survey study. The most important predictors of motivation for sexual activity are the importance of and enjoyment of sex in the person's earlier years.³⁴ Those who report satisfying relations before menopause are likely to continue afterward. Problems can be divided into difficulty with interest, with arousal, with achieving orgasm, and with pain during coitus.

Androgen levels can play a role in problems with decreased libido.³⁵ It is difficult to sort out the effects of changing estrogen and testosterone levels on libido from problems caused by stress and changes in the patient's social situation and relationships with partners. The frequency of intercourse may reflect male sexual dysfunction and not indicate the female partner's libido levels.³⁶ In general, studies have shown no correlation between hormone levels and reported sexual activity. Vaginal atrophy scores, however, do correlate with decreased frequency of sexual activity. Traupmann³⁷ found that 106 of 240 women surveyed between the ages of 50 and 82 were still having intercourse. There may exist an “interest-activity gap” because many patients cite lack of a partner as the reason for cessation of sexual activity. Because 70% of women older than 75 are widows, this is an issue for thousands of women. Newman found that 54% of married versus 7% of single, widowed, or divorced subjects were still sexually active.³⁸ Many complaints are signs of relationship difficulties or changes in the nature of the relationship between two partners, whose passage through midlife is taking them in different directions. Even advances in therapy can alter the balance. The introduction of Viagra, which has allowed many formerly impotent men to again participate in coitus, may cause other issues as the status quo of the relationship changes. Aging in and of itself is associated with decreased pelvic blood flow and an increased length of time needed to reach orgasm with stimulation. This can occur in women who previously experienced no difficulties climaxing. Dyspareunia is common, affecting 13% of older women surveyed.³⁹ HRT can help with pain due to atrophy.

In summary, the physician should inquire about sexual activity, satisfaction, and problems. In addition to taking a history, prescribing HRT or lubricants, and encouraging regular intercourse to maintain vaginal function, physicians can also help patients by helping them alter behaviors and attitudes that are contributing to problems. Referral to a specialist or sex therapist may be helpful.

Pelvic floor prolapse refers to relaxation of any or all parts of the pelvic floor, including cystocele, urethrocele, rectocele, uterine prolapse, and in posthysterectomy patients, eversion of the vaginal vault and enterocele. Treatment should address the degree of discomfort and function limitation the patient is experiencing and any associated urinary or fecal incontinence. Asymptomatic patients do not require treatment unless ulceration becomes a problem. No studies address prophylactic treatment of prolapse to slow its progression. Patients who have sufficient levator muscle tone to retain a pessary can be treated indefinitely in this way. Sexually active patients can use certain types of pessary or learn to insert and remove them on their own. Pessary use is addressed in detail in Chapter 87.

Surgery for prolapse should be reserved for those who can tolerate these elective procedures without excessive risk and whose life expectancy justifies it. The procedure selected depends on the patient's activity levels and sexual functioning. LeFort colpocleisis should be reserved for patients who are not sexually active and have been counseled on the loss of a functional vagina. Other procedures include vaginal hysterectomy and anterior and posterior repair with suspension of the vaginal cuff by McCall's cul-de-plasty or uterosacral shortening. Sacrospinous fixation and abdominal sacral colpopexy are also used for prolapse, especially for treatment of vaginal vault prolapse. Paravaginal and other repairs that involve the pubococcygeal muscles or fascia have also been described.

The International Continence Society defines incontinence as urinary leaking that is “objectively demonstrable and a social and hygienic problem.”^11,40 The National Institutes of Health consensus conference on this topic, whose guidelines have been recently updated, estimated that 15% to 30% of community-dwelling women age 65 and older and 50% of nursing home residents experience some degree of urinary incontinence.¹³ The prevalence in women is twice that in men. Elderly women are more likely to experience detrusor instability than their younger counterparts, in whom stress incontinence is most common. They are also more likely to develop interstitial cystitis and urinary tract infections. Age-related changes such as declining estrogen levels, detrusor muscle degeneration, lower urethral closure pressure, and neurotransmitter dysfunction⁴¹ may play a role. As with other conditions in the geriatric population, continence can be the result of a fragile state of balance that is easily disrupted. Transient causes of incontinence should be sought before undertaking an extensive workup. These causes include infection, medications, constipation, delirium, and mobility problems.

The most common source of bacteremia in the elderly population is urinary tract infection (UTI). UTIs are addressed elsewhere in detail (chap. 44). In some postmenopausal patients, incontinence is the presenting complaint. The prevalence of bacturia in the elderly increases with age and debility,⁴² and this may contribute to higher infection rates. Atrophic vulvovaginitis is also a risk factor for UTI, and use of estrogen creams has been shown to decrease infection rates in patients with recurrent UTIs.⁴³ The most common organisms are Escherichia coli, enterobacteriaceae, and enterococci.⁴⁴ About one half of UTIs in the older population are nosocomial.

A thorough medication history can identify incontinence caused by or aggravated by diuretics, α-adrenergic blockers, and cholinergic drugs. Many over the counter remedies can affect continence. The other reversible causes of incontinence such as constipation or excessive consumption of caffeine, alcohol, and cigarette smoking (all of which can worsen or cause detrusor instability) do not require extensive evaluation other than a history to initially address. Delirium and dementia can cause incontinence by interfering with volition to reach a restroom. Functional incontinence can result when restricted mobility, difficulty undressing because of arthritis, and or other conditions make toileting without assistance difficult for the patient. Patients who do not respond to simple measures of treatment are candidates for urodynamics, especially if surgical repair of stress incontinence is a consideration. Behavioral measures for detrusor instability are preferred over medications because of the lack of side effects.⁴⁵

The elderly are more susceptible to incontinence that has a neurologic basis at the cerebral, pontine, or spinal cord levels. Screening for lower extremity abnormalities on examination is indicated for every patient.⁴⁶ Older women have a higher baseline rate of intrinsic sphincter deficiency. This is a type of stress incontinence that requires different therapy from that for genuine stress incontinence with normal urethral closure pressure. A tenuous equilibrium exists between the storage and micturition functions of the bladder in many older patients. A patient may have simultaneous incontinence and inability to adequately empty the bladder because of detrusor muscle dysfunction. This condition is called detrusor hyperactivity with impaired contractility. As many as one half of nursing home residents may have this problem, and it can be difficult to manage.⁴⁷ Urge incontinence with an abnormally elevated postvoid residual is a sign, but definitive diagnosis requires urodynamics. Treatment options include anticholinergic drugs along with straining, frequent voiding, or intermittent self-catheterization.

Another important issue is identifying occult incontinence in patients who are undergoing surgery to correct pelvic floor prolapse. It is thought that without prophylactive urethropexy, 36% to 80% of these patients may become incontinent after they undergo reduction of the occluding procidentia, cystocele, or enterocele.⁴⁸ Testing for this problem has not been standardized, although many investigators advocate urodynamic testing with the prolapse reduced by a speculum or pessary.⁴⁹ If stress incontinence is demonstrated, some type of urethropexy should be done along with the primary procedure.

Because the incidence of incontinence that is caused by detrusor instability rises and that caused by genuine stress incontinence falls as the population being studied ages, it is useful to consider empiric treatment for detrusor instability in patients with normal postvoid residuals who complain of urgency. Infection should be excluded, and those at risk for bladder carcinoma (i.e. smokers) should be assessed with urine cytology and cystoscopy.

Incontinence in the nursing home setting is a large problem. The Omnibus Reconciliation Act of 1989 requires that all patients entering nursing homes be screened as to their continence status, using the parameters in Table 4. Prompted or timed voiding means actively checking patients for wetness and encouraging them to void every 2 hours. This technique, as well as assistance with toileting and the use of adult diapers when incontinence cannot be controlled, is preferable to the use of indwelling Foley catheters in female patients. Prolonged urethral catheterization is associated with infection, urethral sphincter damage, and vesicovaginal and urethrovaginal fistulas. The nursing home environment should be carefully evaluated and designed for toilet access, commodes, lighting, need for grab bars, and mobility aids such as self-rising chairs. Garments should be easy to take on and off (e.g. with Velcro fasteners).⁵⁰

TABLE 4. Omnibus Reconciliation Act: Recommended Evaluations for All Nursing Home Admissions

  Assessment of bowel and bladder function
  Review of medications
  Observation of voiding behavior
  Identification of antecedent of incontinence
  Evaluation of responsiveness to timed voiding
  Fecal impaction treatment
  Pelvic examination
  Urinalysis
  Estimation of postvoid residual volume

Gynecologic cancers deserve particular attention in the elderly because their incidence increases with age. Screening for cervical, vulvovaginal, endometrial, and ovarian cancer should be done at annual visits. There is no upper age limit for Pap smear testing. The group older than 65 years of age accounts for 25% of the incidence and 40% of the deaths from cervical cancer.^51,52 The normally slow progression of disease from dysplasia to invasion allows effective therapy to prevent cancer. The American College of Obstetrics and Gynecology recommends annual screening for at least 3 years, with the option to perform smears less frequently at the discretion of the physician after three normal results. Hysterectomy does not eliminate the need for cytologic assessment, because vaginal cancers and dysplasia can occur at the cuff margin. If the patient has no history of dysplasia, the frequency of Pap smears after removal of the uterus can be decreased. Vaginal cancers make up less than 1% of all gynecologic malignancies, but they peak in incidence between the ages of 60 and 70. More than 75% of all invasive vulvar carcinomas are diagnosed in women older than 60. Risk factors include smoking, immunosuppression, and other lower genital tract cancer or dysplasia.

Endometrial cancer is diagnosed at a median age of 61. The best screening consists of aggressive evaluation of all postmenopausal bleeding or spotting, especially in patients not on hormone replacement or those who use tamoxifen for treatment of breast cancer. Patients should be routinely asked about bleeding. The most common cause is endometrial atrophy, but the entire genital tract should be carefully examined. Cervical polyps as a cause of postmenopausal bleeding decrease in incidence after the sixth decade. Other sources of spotting are myomas, polyps, endometritis, and endometrial hyperplasia. Obesity, nulliparity, early menarche, late menopause, hypertension, and diabetes are all risk factors for this type of cancer. Office endometrial biopsy is the initial procedure of choice, but may be more difficult because of cervical stenosis. If the office biopsy indicates atypia with hyperplasia or is inadequate, a full dilatation and curettage (D&C) should be done. Uterine ultrasound with saline introduced into the cavity can measure endometrial thickness and delineate polyps or masses in the endometrial cavity. Hysteroscopy has improved the diagnostic rate of D&C because focal biopsy of small polyps can be done. Advanced age is a poor prognostic variable in 5-year survival rates for endometrial cancer. If uterine sarcoma or other müllerian tumors are the cause of bleeding, they may not be sampled during D&C. Patients on hormone replacement therapy whose withdrawal bleeding deviates from the usual pattern deserve full evaluation.

Unfortunately, no test other than the annual pelvic examination has proved to be adequately sensitive or specific for ovarian cancer screening. This disease increases at an age-specific rate until age 81, but it peaks at age 60. It is estimated that 45% of ovarian tumors in older women are benign, and 42% are malignant epithelial tumors.⁵³ All adnexal masses should be considered potentially malignant until proved otherwise by pathologic examination. Endometriosis accounts for only 3% of masses in women 40 years old or older. Postmenopausal women can still develop benign ovarian cysts, such as germinal inclusion cysts, despite the fact that they are not ovulating. Assessment of pelvic masses in this age group should include screening for breast and colon cancers because of the high rate of metastases to the ovaries. Fallopian tube carcinoma also peaks in this age group. It classically manifests with pain, watery vaginal discharge, and a pelvic mass. It is a rare condition, and the diagnosis is usually made intraoperatively. The standard management of adnexal masses in the elderly has been laparotomy through a midline incision for all cases.

The feasibility of serial ultrasound and CA 125 testing has been addressed by several studies. Creasman and Soper first noticed that malignancy in an enlarged postmenopausal ovary was unusual.⁵⁴ Size was found to be a prognostic sign; in one study, only 1 of 32 tumors smaller than 5 cm were malignant,⁵⁵ whereas another found a 15% rate of malignancy in cysts smaller than 5 cm.⁵⁶ Parker found that 25 masses with reassuring ultrasonic characteristics and a normal CA 125 level were all benign, and they were successfully treated through the laparoscope.⁵⁷ As more studies are done on this issue, perhaps more patients with incidental ultrasonic findings of ovarian cysts can avoid laparotomy.⁵⁸ Aspiration of cysts for cytology with computed tomography or ultrasound guidance is another option in patients too ill to tolerate laparotomy. This practice is not generally recommended for diagnosis because of the risk of spilling and seeding tumor cells and because of the high rate of false-negative cytologic results. As for all gynecologic malignancies, age should not deter aggressive surgical management in patients who are otherwise candidates for laparotomy.

The three leading causes of death for patients 55 years old or older are cancer, cardiac disease, and cerebrovascular accident. Cigarette smoking, hypertension, hypercholesterolemia, diabetes, obesity, and a sedentary lifestyle are risk factors for these conditions that can be addressed in screening visits. Many of these risk factors can be favorably affected by hormone replacement. Historically, hormone replacement therapy has been offered to and used by only a small proportion of the women who could benefit from it. There is now more evidence that starting HRT in women older than 65 can have positive effects on their health.

Who should take HRT, at what age, and for how long? The major advantages of its use are in prevention of cardiac disease, osteoporosis, urogenital atrophy, and possibly colon cancer and cognitive decline. The favorable risk-benefit profiles are less clear for women older than 65 than for those in their fifties, but there is evidence to support its use to age 75 and beyond. Those already using estrogen to prevent cardiac disease and osteoporosis should continue indefinitely. The risks of breast cancer may be increased (relative risk of 1.3) in women who use HRT longer than 15 years, but the overall mortality rate seems to be less even in this group of women.^59–62 More information is needed on this issue.

Prevention and treatment of osteoporosis is the second major estrogen-related prevention issue in women older than 65. Physicians should assess bone density status, calcium intake, and use of prophylactic medications at health maintenance visits. It is known that estrogen replacement can arrest bone loss no matter how late it is begun, and it can increase bone density⁶³ and decrease the risk of femoral neck and vertebral fractures. This in not a trivial issue, because one fourth of all women have spinal compression by age 60, 20% of white females have a hip fracture by age 90, and 15,000 women die annually as a result of the consequences of osteoporotic fracture. Unfortunately, HRT is not routinely prescribed for women who have or are at risk for osteoporosis.⁶⁴ At the least, calcium supplementation to a level of 1500 mg per day should be routinely advised, along with weight-bearing exercise. Patients who cannot take or do not tolerate HRT can be offered other medical treatments such as aledronate and calcitonin. Dual-energy x-ray absorptiometry (DEXA) scanning is recommended for all women older than 60. DEXA scanning can also be used to follow response to treatment. Prevention of falls in the elderly is also important in preventing fractures.^65,66

Cardiovascular disease causes 46% of deaths in women in the United States, compared with 4% of deaths from breast cancer.^67–70 Studies of HRT show a consistent 50% reduction of coronary artery disease in estrogen-treated women in their fifties compared with untreated controls.^{6,11,71–90 91–105} Some studies demonstrate that estrogen replacement therapy decreases the risk of cardiac death in women with angiographically proved coronary stenosis.^90,91,94,106 The HERS trial,¹⁰⁷ although controversial, showed an initial increase in death in a similar population treated with HRT. The possible mechanisms for these effects include regulation of plasma lipids; autonomic and neuroendocrine regulation of systemic vascular resistance and blood pressure, modulation of vascular endothelial and smooth muscle cells, decreasing thromboembolic risk through fibrinogen and factor VII, and modulation of the activity of cardiac myocytes. An extensive discussion of this topic is beyond the scope of this chapter. The data on beginning HRT for prevention or treatment of cardiac disease in those older than 65 years of age is growing rapidly.^108,109 Little is known about selective estrogen receptor modulators (SERMs) and cardiovascular disease prevention. For example, it is known that raloxifene differs from estrogen in its effects on high-density lipoproteins, fibrinogen, and plasminogen activator inhibitor-1,¹¹⁰ but long-term studies on mortality and morbidity are not yet available.

HRT has benefits in preventing and treating some urogenital problems associated with menopause. It is also being investigated as a preventive and treatment modality for Alzheimer's disease and other forms of cognitive decline. More information on this subject and others should be available at the conclusion of the Women' Health Initiative Trial.

Gynecologists can have a significant impact on the health of the elderly female patient as specialists and primary care physicians. They can have a leadership role in this important area of women's health care.

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