Genitourinary syndrome of menopause

Menopause is the permanent cessation of menses from ovarian follicular depletion, confirmed retrospectively after 12 months of amenorrhea around a mean age of 51 years. Management centers on treating moderate to severe vasomotor symptoms with the lowest effective dose of hormone therapy in appropriately selected candidates, alongside bone and cardiovascular risk assessment.

Dyspareunia is triaged by pain timing and location, not treated as one disease: superficial pain at the introitus on entry points to vulvovaginal atrophy, infection, vulvodynia, or vaginismus, while deep pain with penetration points to endometriosis, pelvic inflammatory disease, or a pelvic mass, and each branch has its own diagnostic and treatment pathway.

Candida vulvovaginitis presents with vulvar itching, burning, and thick curdy white discharge at a normal vaginal pH; uncomplicated disease clears with a single 150 mg oral fluconazole dose or a short topical azole course, while complicated or recurrent disease needs a longer induction course followed by suppressive therapy.

Bacterial vaginosis is a polymicrobial dysbiosis of the vagina caused by loss of lactobacilli and anaerobic overgrowth, diagnosed clinically by the Amsel criteria and treated with oral or intravaginal metronidazole or clindamycin.

Trichomonas vaginalis is a flagellated protozoan sexually transmitted infection that presents with malodorous frothy yellow-green discharge and a strawberry cervix but is frequently asymptomatic, especially in men. Diagnosis rests on nucleic acid amplification testing of vaginal secretions, and treatment is a single 2 g oral dose of metronidazole or tinidazole with partner treatment and retesting in 3 months for high reinfection rates.

Vulvar lichen sclerosus is a chronic inflammatory dermatosis causing porcelain-white atrophic plaques, itching, and scarring of the vulva, confirmed by biopsy and treated with an ultrapotent topical corticosteroid to relieve symptoms and reduce the lifelong risk of vulvar squamous cell carcinoma.

Urinary tract infection spans uncomplicated cystitis, presenting with dysuria, frequency, and suprapubic pain, through pyelonephritis, presenting with fever, flank pain, and costovertebral angle tenderness, most often from ascending Escherichia coli. Uncomplicated cystitis is treated empirically without culture using nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, while pyelonephritis requires a pre-treatment urine culture and empiric fluoroquinolone or cephalosporin therapy, escalated to hospitalization and broader parenteral coverage for hemodynamic instability, obstruction, or failure to improve.

Abnormal vaginal discharge is triaged at the bedside with vaginal pH, the amine whiff test, and saline/KOH microscopy, and treated with metronidazole for bacterial vaginosis or trichomoniasis, fluconazole or clotrimazole for candidiasis, and ceftriaxone plus doxycycline for cervicitis.

Breast cancer is a malignancy of ductal or lobular epithelium, most often presenting as a firm, painless mass in the upper outer quadrant. Diagnosis rests on core needle biopsy with estrogen, progesterone, and HER2 receptor testing, and first-line treatment pairs breast-conserving surgery or mastectomy with sentinel node biopsy, radiation, and receptor-guided systemic therapy such as tamoxifen or trastuzumab.