A 69-year female patient report dyspareunia Physical examination reveals sparse hair, an introitus that admits two fingers, and a pale, dry vagina. The adult-gerontology primary care nurse practitioner’s initial management is to recommend (Solved MCQ)

A 69-year female patient report dyspareunia Physical examination reveals sparse hair, an introitus that admits two fingers, and a pale, dry vagina. The adult-gerontology primary care nurse practitioner’s initial management is to recommend

A. Daily douching

B. Topical hormonal cream.

C. Topical antibiotic cream.

D. Topical antifungal cream.

Correct Answer: B. Topical hormonal cream

Explanation

Based on the description:

• Patient: 69-year-old female
• Symptoms: Dyspareunia (painful intercourse)
• Physical findings: Sparse pubic hair, vaginal atrophy (pale, dry vagina), introitus narrowed (admitting only two fingers)

These findings are classic for genitourinary syndrome of menopause (GSM), previously called vulvovaginal atrophy. The primary cause is estrogen deficiency after menopause.

Initial Management

For an adult-gerontology primary care NP, first-line management typically includes:

1. Non-hormonal therapies (first-line for mild to moderate symptoms or if hormones are contraindicated):
   • Vaginal moisturizers (used regularly to maintain hydration)
   • Vaginal lubricants (used during sexual activity)
2. Local estrogen therapy (if symptoms are moderate to severe and no contraindications):
   • Vaginal estrogen cream, tablet, or ring
   • Benefits: Restores vaginal epithelium, improves elasticity, reduces dyspareunia, improves urinary symptoms
3. Lifestyle measures:
   • Regular sexual activity or vaginal dilator use may help maintain vaginal elasticity.

Note: Systemic hormone therapy is generally not first-line solely for GSM in older postmenopausal women unless they have other menopausal symptoms.

✅ Answer (Initial Management Recommendation):

• Start with non-hormonal vaginal moisturizers and lubricants.
• If symptoms persist or are moderate/severe, consider low-dose local vaginal estrogen therapy.

Other Options Details

Here’s a detailed explanation of the options you listed:

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A. Daily douching

• Definition: Douching is the practice of rinsing or cleaning the vagina with water or other fluids.
• Purpose/Use: Some people use it for personal hygiene or to try to prevent infections.
• Considerations: Daily douching is generally not recommended because it can disrupt the natural vaginal flora, leading to:
  • Increased risk of bacterial vaginosis
  • Irritation or inflammation
  • Higher susceptibility to infections, including sexually transmitted infections (STIs)
• Summary: Not a therapeutic treatment; more of a hygiene practice but often harmful if done daily.

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B. Topical hormonal cream

• Definition: A cream applied directly to the skin or mucosal surfaces that contains hormones, usually estrogen or progesterone.
• Purpose/Use: Used to treat conditions caused by hormonal imbalances, such as:
  • Vaginal atrophy (thinning of vaginal walls due to menopause)
  • Certain local symptoms of menopause (dryness, irritation)
  • Some menstrual irregularities if prescribed locally
• Considerations: Must be used under medical supervision; potential side effects include localized irritation, systemic absorption (rare), or interactions with other hormonal treatments.

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C. Topical antibiotic cream

• Definition: A cream containing antibiotics applied directly to an area affected by bacterial infection.
• Purpose/Use: Treats localized bacterial infections, e.g., skin infections, minor wounds, or specific vaginal infections (if prescribed).
• Considerations:
  • Overuse can lead to antibiotic resistance
  • Not effective against fungal or viral infections
  • Should be used according to prescription and duration

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D. Topical antifungal cream

• Definition: A cream containing antifungal agents applied directly to treat fungal infections.
• Purpose/Use: Commonly used for:
  • Vaginal yeast infections (Candida)
  • Skin fungal infections like ringworm, athlete’s foot, or jock itch
• Considerations:
  • Usually effective for mild to moderate fungal infections
  • May cause minor skin irritation
  • Should not be used for bacterial infections as it won’t work

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In short: Option Treats / Purpose Key Consideration Daily douching Hygiene (not recommended) Can disrupt vaginal flora, risk infections Topical hormonal cream Hormonal-related issues Needs medical supervision Topical antibiotic cream Bacterial infections Overuse → resistance Topical antifungal cream Fungal infections Only effective for fungi, not bacteria

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Writer: Vandita Singh, Lucknow (GS India Nursing Group