Some vaginal lesions are asymptomatic and are noted incidentally on examination. Fibroepithelial polyps consist of polypoid folds of connective tissue, capillaries, and stroma covered by vaginal epithelium. Although they can be excised easily in the office, their vascularity can be troublesome, and excision is not necessary unless the diagnosis is in question. Cysts of embryonic origin can arise from mesonephric, paramesonephric, and urogenital sinus epithelium. Gartner’s duct cysts are of mesonephric origin and are usually present on the lateral vaginal wall. They rarely cause symptoms and, therefore, do not require treatment. Other embryonic cysts can arise anterior to the vagina and beneath the bladder. Cysts that arise from the urogenital sinus epithelium are located in the area of the vulvar vestibule. Vaginal adenosis, the presence of epithelial-lined glands within the vagina, is associated with in utero exposure to diethylstilbestrol. No therapy is necessary other than close observation and periodic palpation to detect nodules that may need to be evaluated by biopsy to rule out vaginal clear cell adenocarcinoma (see Chapter 36).
Women will sometimes describe a bulging lesion of the vagina and vulvar area, variably associated with symptoms of pressure or discomfort. The most common cause of such a lesion is one of the disorders of vaginal support. Management of these conditions is discussed in Chapter 27. Other genital lesions, such as urethral diverticula or embryonic cysts, may cause similar symptoms.
Differential Diagnosis The causes of postmenopausal bleeding and the percentage of patients who seek treatment for different conditions are presented in Table 14.16.
Hormone therapy may be used to manage troublesome menopausal symptoms; it is recommended to treat with the lowest effective dose with the risks versus benefits regularly reviewed by a woman and her doctor (246). Women who are taking hormone therapy during menopause may be using a variety of hormonal regimens that can result in bleeding (see Chapter 34). Because unopposed estrogen therapy can result in endometrial hyperplasia, various regimens of progestins are typically added to the estrogen regimen; they are given in a continuous fashion, although they may be given in a sequential fashion for women within 1 year of menopause (246).
Table 14.16 Etiology of Postmenopausal Bleeding
From Hacker NF, Moore JG. Essentials of obstetrics and gynecology, 3rd ed. Philadelphia: WB Saunders, 1998:635, with permission.
Endometrial sampling is indicated for any unexpected bleeding that occurs with hormonal therapy. A significant change in withdrawal bleeding or breakthrough bleeding (e.g., absence of withdrawal bleeding for several months followed by resumption of bleeding or a marked increase in the amount of bleeding) should prompt endometrial sampling.
Patient adherence to hormonal regimens is a significant issue with hormone therapy, with the challenges of oral therapy mitigated by nonoral routes of administration (247). Missed doses of oral medication and failure to take the medication in the prescribed fashion can lead to irregular bleeding or spotting that is benign in origin but that can result in patient dissatisfaction (248).
The problems that women most often report with hormone therapy include vaginal bleeding and weight gain. The use of a continuous low-dose combined regimen has the advantage that for many women, bleeding will ultimately cease after several months, during which irregular and unpredictable bleeding may occur (248,249). Some women are unable to tolerate these initial months of irregular bleeding. The risk of endometrial hyperplasia or neoplasia with this regimen is low.