. A 60-year-old woman presents with complaints of pain during intercourse. She describes the pain as sharp and constant during sexual activity, and there is a lack of lubrication. This discomfort is very bothersome to her because she wishes to continue an active sex life. She underwent surgical menopause at age 44 due to uterine fibroids and heavy bleeding. She used oral estrogen until age 50; she has used no hormonal therapy since then. On physical examination you note significant urethral and vaginal atrophy.
Which of the following is the best treatment option for this patient?
A. Commercial lubricant (K-Y lubricating jelly)This patient has dyspareunia or pain during intercourse. She has been postmenopausal for many years without hormone (estrogen) replacement. A commercial lubricant would be helpful for vaginal dryness but will not treat the underlying cause of her urogenital atrophy, which is hypoestrogenemia. She has no other symptoms of menopause (such as vasomotor symptoms or sleep disturbance) that impair quality of life. Therefore oral estrogen is not required. She denies depressive symptoms. The best treatment option for this patient is to treat the underlying disorder of urogenital atrophy with topical estrogen applied to the vagina. A commercial lubricant could be used as needed, but would be in addition to the vaginal hormone cream. Though sildenafil has been shown to be efficacious in the treatment of antidepressant-associated sexual dysfunction, it is not FDA-approved for use in women. Nothing on examination suggests fungal vaginitis.