Menstruation + Infection Flashcards
(90 cards)
1
Q
Primary amenorrhea is defined as
A
Primary amenorrhea is the failure of menses to occur by age 15 years (some sources say 16 years), in the presence of normal growth and secondary sexual characteristics (breast development, axillary or pubic hair).
At age 13 years, if no menses have occurredand there is a completeabsence of secondary sexual characteristics, evaluation for primary amenorrhea should begin
2
Q
MCC of secondary amenorrhea
A
Intrauterine pregnancy is the most common cause of secondary amenorrhea. The first step in the workup of amenorrhea should almost always be a pregnancy test.
3
Q
17-year-old female who is concerned that she has not yet had her period. She is sexually active and uses condoms consistently. She does not use other forms of contraception. On physical exam, there is normal breast maturation. The uterus is not palpable, and this is confirmed by pelvic ultrasound. Karyotype testing is performed and returns as 46 XX. Her serum testosterone levels are within normal limits.
A
Primary amenorrhea
4
Q
3-year-old female who is concerned that she has not had her menses over a period of four months. She is also very distressed about increased hair growth. She reports having to shave frequently above the lip, chin, chest, and lower back. Prior to this, she had regular menses. The patient’s weight is 168 lbs. (76.2 kg) and height 5 feet and 1 inch (154.9 cm). On physical examination, there is hair above the lip and chin area. She also has acne on her cheeks and forehead. Hyperpigmented plaques of the skin are found on the nape of her neck. Bilateral enlarged ovaries are palpated on pelvic examination. β-hCG is negative and LH: FSH is 3.
A
Secondary amenorrhea
5
Q
MCC of primary amenorrhea
A
- Pregnancy
- Imperforate hymen
- Gonadal dysgenesis - Turner’s syndrome (46 XO) - short web neck
- Müllerian agenesis (absent uterus and vagina)
- HPO axis abnormalities - Anorexia, bulimia, weight loss, excessive exercise
6
Q
Absence of menses for 3 months in a woman with previously normal menstruation or 6 months in a woman with a history of irregular cycles
A
Secondary amenorrhea
7
Q
Labs for primary amenorrhea
A
- Quantitative βHCG
- FSH, prolactin, TSH, T3, Free T4 estrogen, progesterone
8
Q
Excessive uterine bleeding and prolonged menses that is NOT caused by pregnancy or miscarriage, diagnosis of exclusion, look for an underlying endocrine disorder
A
Dysfunctional uterine bleeding
9
Q
a 35-year-old woman with concerns about heavy menstrual periods for the past year that occur at irregular intervals. She explains that sometimes her menses come twice a month but other times will skip two months in a row. Her menses may last 7 to 10 days and require 10 to 15 thick sanitary napkins on the heaviest days. She admits to some fatigue, but she denies any lightheadedness. She has no pain with menses or intercourse and denies any vaginal discharge. She has had normal Pap smears in the past. She is in a stable monogamous relationship with her husband and denies a history of STIs. On physical examination, her blood pressure is 120/ 80 mm Hg and her body mass index (BMI) is 32. Her pelvic examination is normal.
A
Dysfunctional uterine bleeding
10
Q
menses that occur more frequently (menses < 21 days apart)
A
Polymenorrhea
11
Q
menses that involve more blood loss (> 7 days or > 80 mL) during menses
A
Hemorrhagic or hypermenorrhea
12
Q
prolonged/heavy bleeding (>7 days or >80 mL); regular intervals
A
Menorrhagia
13
Q
uterine bleeding that occurs frequently and irregularly between menses
A
Metorrhagia
14
Q
more blood loss during menses and frequent and irregular bleeding between menses
A
Menometrorrhagia
15
Q
Period = long intervals > 35 days
A
Oligomenorrhea
16
Q
AUB in the absence of an anatomic lesion, caused by a problem with the hypothalamic-pituitary-ovarian axis
A
Dysfunctional uterine bleeding
17
Q
Dysfunctional uterine bleeding dx
A
Diagnosis of exclusion, Uterine Dilation and Curettage is the gold standard diagnosis
- Urinary β-hCG levels—r/o pregnancy
- Labs: CBC, iron studies, PT, PTT, TSH, progesterone, prolactin, FSH, LFTs
- Progestin trial—if the bleeding stops, anovulatory cycles confirmed
- Ovulation journal, Pap smear
- Pelvic U/S, endometrial biopsy, HSG, hysteroscopy
- Urinary β-hCG levels—r/o pregnancy
18
Q
Tx of dysfunctional uterine bleeding
A
19
Q
a 19-year-old nulligravid college female who complains of dull, throbbing, cramping lower abdominal pain during menses for the past three years. She reports nausea and vomiting during menses but denies irregular or heavy periods, pain with intercourse, or abdominal pain outside of menses. Pain tends to peak 24 h after the onset of menses and subsides after 2 to 3 days. A pelvic exam is normal.
A
Dysmenorrhea
20
Q
Refers to uterine pain around the time of menses, which can either be primary or secondary
A
Dysmenorrhea
21
Q
S/S of primary dysmenorrhea
A
- Painful uterine muscle activity due to an excess of prostaglandins (F2a)
- Teens-early 20s, declines with age, no associated pelvic pathology
- Risk factors include menarche before age 12, nulliparity, smoking, family history, obesity
- Pain with menstruation, lower abdominal, intermittent, “labor-like” on days 1-3
- Nausea, vomiting, diarrhea (smooth muscle contraction), headache
- Normal pelvic exam
22
Q
Tx of primary dysmenorrhea
A
Treatment: NSAIDs and oral contraceptive pills
23
Q
Secondary dysmenorrhea mcc
A
- Painful menstruation caused by clinically identifiable cause
- Etiology: Endometriosis, adenomyosis, polyps, fibroids, PID, IUD, tumors, adhesions, cervical stenosis/lesions, psych
- Pain with menstruation begins mid-cycle and increases in severity until end
- Common women age (20-40 s)
24
Q
Tx of secondary dysmenorrhea
A
Tx underlying cause
25
**12 or more months of amenorrhea** occurring at a **mean age of 51 years**
**Menopause**
26
the transition between reproductive capability and menopause hallmark is irregular menstrual function, lasts 3-5 years
Perimenopause
27
Onset of menopause \< **40 years old**
**premature ovarian failure**
28
FSH and estradiol levels of menopausal women
**FSH and estradiol levels** **(FSH \> 30)** **with ↓ estradiol** (although not necessary for diagnosis)
29
Tx of menopause
* **Estrogens** are used to treat hot flashes
* **If uterus: HRT (estrogen + progesterone), if no uterus (ERT)**
* Woman with an **intact uterus** **should not use estrogen alone** because of the i**ncreased risk of endometrial cancer**
* **Progestins:** Hot flashes, increased risk of breast cancer
* HRT—severe menopausal symptoms (hot flashes, night sweats, vaginal dryness)
* “Smallest dose for shortest possible time and annual reviews of the decision to take hormones”
* HRT should not be used to prevent cardiovascular disease due to slightly increased risk of breast cancer, MI, CVD, DVT
* Hormone therapy effect on lipid profile: **HDL** and **TG** levels **↑**, **LDL** levels **↓**
30
Contraindications for HRT
* [_↑ triglycerides_](https://smartypance.com/lessons/lipid-disorders/hypertriglyceridemia/)
* Undiagnosed vaginal bleeding
* [Endometrial cancer](https://smartypance.com/lessons/neoplasms-of-the-breast-and-reproductive-tract/endometrial-cancer/)
* History of [breast CA](https://smartypance.com/lessons/neoplasms-of-the-breast-and-reproductive-tract/cancer/) or estrogen-sensitive cancers
* CVD History
* [DVT](https://smartypance.com/lessons/vascular-disease/venous-thrombosis/) or [PE](https://smartypance.com/lessons/pulmonary-circulation/pulmonary-embolism-reeldx418/) history
31
Non hormonal therapies for menopause
Cool temperatures, avoid hot, spicy foods or beverages, avoid ETOH, exercise, soy
* Alternative drugs for **vasomotor symptoms**
* SSRIs (paroxetine)
* SNRIs
* clonidine
* gabapentin
32
**Follicular (proliferative) phase of menstrual cycle**
* The follicular phase is the first part of the menstrual cycle
* It goes from day 0 to day 14
* First, **GnRH (from the hypothalamus)** stimulates **FSH** and **LH** release **(from anterior pituitary)**
33
What causes ovulation
* Estrogen secretion is increased even more from the follicle in **FOLLICULAR PHASE .** It induces an **LH spike, which causes ovulation**
34
Which phase is 15-28 of the cycle
Luteal phase
35
What happens in the luteal phase
* After ovulation, the **follicle becomes** the **corpus luteum,** which secretes **progesterone** and provides negative feedback to FSH and LH
* If pregnancy does not occur, the corpus albicans is formed, which no longer secretes estrogen and progesterone
36
Which phase does endometrial sloughing or menses occur in?
* This decrease in hormones leads to **endometrial sloughing** or **menses**
* To begin a new follicular phase of the menstrual cycle, **GnRH is secreted**.
37
DSM-5 criteria for PMDD
In the majority of menstrual cycles, **at least five symptoms** must be present in the **final week before the onset of menses**, start to **improve** within a few days **after the onset of menses**, and become **minimal or absent** in the **week post menses**.
**One (or more)** of the following symptoms must be present:
* Marked **affective lability** (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
* Marked irritability or anger or increased **interpersonal conflicts.**
* Marked **depressed mood**, feelings of hopelessness, or self-deprecating thoughts.
* Marked **anxiety**, tension, and/or feelings of being keyed up or on
38
a 25-year-old female who complains of **abdominal bloating, headache, irritability, depression, poor sleep quality,** and **breast tenderness.** These symptoms occur on a monthly basis **5 days before menses.** Her symptoms greatly improve **within 4 days of the onset of menses**.
Premenstrual syndrome
39
[**Premenstrual syndrome**](https://smartypance.com/lessons/menstrual-disorders/premenstrual-syndrome/) **caused by**
* Caused by an **imbalance of estrogen** and **progesterone** along with **excess prostaglandin** production
* Symptoms during the **luteal phase** **(1-2 weeks before menses)** - Bloating, irritability. PMDD- causes marked disruption in functioning.
* Symptoms resolve at the onset of mense
40
[**Premenstrual syndrome**](https://smartypance.com/lessons/menstrual-disorders/premenstrual-syndrome/) **dx**
is based on **history** and **physical exam**
* ACOG criteria: Need **one** of the **following symptoms** is present during the **5 days before menses** and **abates within 4 days of the onset of menses**
* **Somatic:** Breast tenderness, abdominal bloating, headache, edema
* **Affective:** Irritability, depression, angry outbursts, anxiety, social withdrawal, confusion
41
Tx of premenstrual syndrome
**Exercise** and **stress reduction** are beneficial in general and should be recommended on this basis
* **SSRIs are first-line options** for women with moderate to severe premenstrual symptoms who do not desire contraception
* Can be administered as continuous daily therapy or **may be used cyclically 2 weeks prior to the menstrual cycle**
* **Combined estrogen-progestin oral contraceptive** as first-line therapy if contraception is a high priority **(stops ovulation and stabilizes hormone levels)**
* Start with a 3 mg drospirenone (DRSP)/20 mcg ethinyl estradiol (EE) COC ([Yazmin](https://online.epocrates.com/drugs/253110/Yasmin/Monograph)) with a four-day pill-free interval as the first-line pill
* If symptom relief with the COC monotherapy is incomplete, an SSRI can be added
* **GnRH agonist therapy:** For women who have not responded to or cannot tolerate SSRIs or OCs and continue to experience severe symptoms
* **Surgery** (bilateral oophorectomy/bilateral salpingoophorectomy [surgical menopause]) is considered only as a last resort
42
Gonorrhea tx
[**CDC recommends**](https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm) a single **500 mg intramuscular dose of** **ceftriaxone** for uncomplicated gonorrhea. Treatment for coinfection with [**chlamydia**](https://smartypance.com/lessons/bacterial-disease/chlamydia/) with oral **doxycycline (100 mg twice daily for 7 days)** should be administered when a chlamydial infection has not been excluded.
43
sx of gonorrhea in women vs men
* **Women:** often **asymptomatic**, a prolonged infection can result in [**pelvic inflammatory disease**](https://smartypance.com/lessons/pelvic-inflammatory-disease/) when the bacterium travels into the pelvic peritoneum
* **Men:** yellow, creamy, profuse, and **purulent** **discharge**
* Can infect any mucocutaneous surface (oral, urethral, vaginal, and anal)
44
**Fitz-Hugh-Curtis syndrome**
gonococcal (or chlamydial) perihepatitis that occurs predominantly in women and causes right upper quadrant abdominal pain, fever, nausea, and vomiting, often **mimicking biliary or hepatic disease**
45
**How can you differentiate gonococcal urethritis from chlamydial urethritis on examination?**
**Gonorrhea** presents with a **purulent discharge from the urethr**a, whereas [**chlamydia**](https://smartypance.com/lessons/bacterial-disease/chlamydia/) **is generally associated with a thinner, white mucous discharge**.
46
Dx of gonorrhea
Diagnosis is made with **Nucleic acid amplification testing (NAAT)**
* For urogenital infections, **vaginal swabs** in **women** (clinician-collected and self-collected) and **first-catch urine in men** are the preferred specimens for NAAT
* For extragenital infections, NAAT, used on pharyngeal and rectal swabs, is also the preferred test
* Patients with confirmed gonococcal infection who have persistent symptoms after appropriate therapy with good adherence and lack of re-exposure should be tested for antibiotic resistant N. gonorrhoeae with **culture and susceptibility testing**
47
Tx of gonorrhea if there is a cephalosporin allergy
* When ceftriaxone cannot be used because of **cephalosporin allergy**, a single **240 mg IM dose of gentamicin** plus a single **2 g oral dose of azithromycin** is an option
* **Cefixime** 800 mg orally as a single dose is another alternative
48
Most common sexually transmitted infection
Chlamydia trachomatis ⇒ Serotypes D-K cause chlamydia
49
Tx of chlamydia
TX: [**The CDC recommended treatment for chlamydia**](https://www.cdc.gov/std/treatment-guidelines/chlamydia.htm#:~:text=Recommended%20Regimens%20for%20Chlamydial%20Infection%20Among%20Adolescents%20and%20Adults) is **doxycycline** 100 mg PO BID × 7 days
50
a 22-year-old patient presents with a complaint of **painful blisters on the vulva** and **vaginal introitus**. She admits to a **prodrome of burning, tingling,** and **pruritus** before the appearance of lesions. Upon examination, you note **vesicles on an erythematous base**.
Herpes simplex
51
Dx of genital herpes
* hus, it is important to confirm the diagnosis of herpes simplex virus (HSV) infection with either of the following techniques: **viral culture (gold standard)**, **polymerase chain reaction (PCR)**, direct fluorescence antibody, and type-specific serologic tests
* Tzanck prep from skin scrapings ⇒ multinucleated giant cells
52
Genital warts are caused by
**Genital warts** caused by **HPV type 6 and 11**
53
Gardasil protects against
**The HPV 9-valent vaccine (Gardasil-9) protects against nine subtypes, including seven types that cause cancer,** and is indicated for females and males ages 9–45 years old.
54
* \>90% of cervical cancer is associated with HPV types
16, 18, 31, 33, and 35
55
Dx of genital warts
DX: **Shave or punch biopsy** confirms the diagnosis, **only if necessary** - uncertain diagnosis, poor response to therapy, atypical appearance, immunocompromised
* [**Koilocytic squamous epithelial cells in clumps**](https://smartypance.com/wp-content/uploads/2018/01/koilocyte-HPV.jpg) are found on a **pap smear** and are typical of **cervical warts**
* **HPV DNA** can be detected on **cervical swabs**
56
Tx of genital warts
TX: **Spontaneous remission** in months to years is typical of skin warts
* Treat to improve symptoms and remove warts
* **The provider may apply podophyllin or trichloroacetic acid (TCA)**
* **Topical imiquimod (Aldara)** cream can be applied by the patient
* **Surgery**: **cryotherapy with liquid nitrogen**, surgical excision, electrocautery, laser, intralesional interferon
57
a 30-year-old woman complains of a **painful sore on her vulva** that first resembled a pimple. On examination, you find an ulcer with **clearly demarcated borders, gray base,** and **foul-smelling discharge**.
Chancroid
58
Etiology of chancroid
* The causative pathogen is **Haemophilus ducreyi**, a gram-negative rod that is very contagious but rarely found in the developed world
* Cases of chancroid in the developing world may be underreported due to the difficulty of definitive diagnosis
59
Sx of chancroid
one or several[**painful genital ulcers**](https://smartypance.com/wp-content/uploads/2021/06/Chancroid.png) on an erythematous base, 1–2cm/0.39–0.79in diameter with sharply demarcated borders; the base of ulcer covered with purulent exudate bleeds easily when scraped
* In about half of patients with chancroid, there will also be **marked lymphadenopathy** in the inguinal chain.
60
Dx of chancroid
Serologic testing for syphilis - RPR/VDRL
* **Gram stain, culture,** and **biopsy** (used in combination because of the high false-negative rates) show the causative agent Haemophilus ducreyi
61
Tx of chancroid
[**_The CDC recommends_**](https://smartypance.com/lessons/womens-health-rotation-infections-pearls/Treatment) single-dose therapy with **ceftriaxone 250 mg IM** **× 1 dose** or azithromycin 1 g PO × one dose
* Fluctuant lymphadenopathy - needle aspiration, drainage to prevent spontaneous rupture
62
**Lymphogranuloma venereum (LGV)**
**ulcerative disease** of the genital area
* It is an **uncommon**, sexually transmitted infection. It is transmittable by vaginal, oral or anal sex
* Its cause is the gram-negative bacteria **chlamydia trachomatis**, especially serotypes **L1, L2, and L3**
63
lymphogranuloma venereum **three stages of infection**
1. **Primary stage** is characterized by the development of [**painless genital ulcers**](https://smartypance.com/wp-content/uploads/2020/04/Lymphogranuloma-venereum.jpg) or papules
2. **Secondary stage** with the development of unilateral or bilateral [**tender inguinal and/or femoral lymphadenopathy**](https://smartypance.com/wp-content/uploads/2020/04/Bubo.jpg) (also called buboes)
3. **Late-stage** with strictures, fibrosis, and fistulae of the anogenital area
64
Dx of **Lymphogranuloma venereum (LGV)**
Diagnosis is by clinical suspicion. Other causes of genital ulceration and inguinal adenopathy should be excluded ⇒ **Serologic testing for syphilis—RPR/VDRL**
* The basis for a **definitive diagnosis** of LGV is on **serology tests** (complement fixation or micro-immunofluorescence) or identification of Chlamydia trachomatis in genital, rectal, and lymph node specimens
65
Tx of **Lymphogranuloma venereum (LGV)**
[**_The CDC recommended treatment_**](https://www.cdc.gov/std/treatment-guidelines/lgv.htm#:~:text=Doxycycline%20100%20mg%20orally%202%20times/day%20for%2021%20days) regimen is **doxycycline** **100 mg orally twice a day given for 21 days**
66
PID
**Infection** that ascends from the cervix or vagina to involve the **endometrium** and or the **fallopian tubes**
67
Etiology of PID
**Infection** that ascends from the cervix or vagina to involve the **endometrium** and or the **fallopian tubes**
* Causative agents include **Gonorrhea** and **chlamydia**
68
Sx of PID
* Common symptoms include **pelvic pain** and **fever**. There may be **vaginal discharge** (cervicitis)
* Complications: **infertility**, ectopic pregnancy, tubo-ovarian abscess (adnexal mass)
69
**Abdominal tenderness**, **cervical motion tenderness**, and **adnexal tenderness** plus one **or more of the following:**
* Temperature \> 38°C
* WBC count \> 10,000/mm3
* Pelvic abscess found by manual examination or ultrasonography
PID
70
Tx of PID
* **Outpatient**: **ceftriaxone IM** 250 mg once + PO **doxycycline** 100 mg BID × 14 d ± PO **Flagyl** 500 mg BID × 14 d
* **Inpatient**
* Severely ill or nausea and vomiting precludes outpatient management
* Consider hospitalization if the diagnosis is uncertain, ectopic and appendicitis cannot be ruled out, pregnancy, pelvic abscess suspected, HIV positive, unable to follow or tolerate outpatient regimen, or failed to respond to outpatient therapy
* **Doxycycline** + IV cefotetan or **cefoxitin** × 48 h until the condition improves, then **PO doxycycline** 100 mg BID × 14 d
* **Clindamycin** + **gentamicin** daily, if normal renal function, ×48 h until the condition improves, then PO **doxycycline** 100 mg BID × 14 days
71
[**painless ulcer (chancre)**](https://smartypance.com/wp-content/uploads/2018/01/chancre.jpg) in the genital or groin region **persisting 3 to 6 weeks**
Primary syphillis
72
**erythematous rash** involving the [**palms and soles**](https://smartypance.com/wp-content/uploads/2018/01/Syphilis-Rash.jpg) or a condyloma lata, which is similar to the lesions of primary syphilis in its infectivity but differs in appearance.
Secondary syphillis
73
systemic involvement and can present with major vessel changes, such as in the aorta, **permanent CNS changes (neurosyphilis)**, or even benign mucosal growths called [**gummas**](https://smartypance.com/wp-content/uploads/2018/01/Syphilitic-Gumma.jpg).
Tertiary syphillis
74
Dx of Syphilis
**RPR/VDRL** and confirmed by the treponemal antibody-absorption test **(FTA-ABS)**. Lyme disease can cause a false positive.
75
Tx of Syphilis
TX: **Benzathine PCN G, 2.4 million units IM × one dose** for primary and secondary disease
* Additional doses if the infection has been for \>1 year or if the patient is pregnant
* If the patient is penicillin-allergic, treat with **doxycycline**
* IV penicillin G (for Gummas) for **congenital and late disease**
76
MCC of vaginitis
Candida
77
**Clumpy or cheesy vaginal discharge**, pruritus, dysuria, burning, dyspareunia, vaginal or vulvar edema, and erythema
Candida vaginitis
78
Dx of candida vaginitis
KOH branching **hyphae**
* **PH \< 4.5 (acidic)**
79
Tx of candida vaginitis
**ral fluconazole (Diflucan)** **150 mg PO x 1 then repeat in 7 days**
* Topical clotrimazole (Gyne-Lotrimin)
* Topical tioconazole (Monistat)
* In severe infections (generally hospitalized patients), amphotericin B, caspofungin, or voriconazole may be used)
80
MCC of bacterial vaginitis
* The causative agent is **Gardnerella** (**anaerobic bacteria**)
81
Sx of bacterial vaginitis
frothy, **grayish-white**, **fishy-smelling** vaginal discharge is noted
82
Dx of bacterial vaginitis
"**Clue cells,"** which are epithelial cells with bacilli attached to their surfaces. On saline wet mount adding 10% KOH of the discharge produces a **fishy odor (+ whiff test)**
* **PH \> 4.5 (BACTERIA = BASIC)**
83
Tx of bacterial vaginitis
First-line treatment is **metronidazole (Flagyl)** either orally or vaginally
* **Metronidazole oral 500 mg PO b.i.d. × 7 days**
* Metronidazole gel 0.75%: 5 g intravaginally daily × 5 days
* Clindamycin 2% cream: 5 g intravaginally QHS × 7 days
* Second-Line Treatment
* Clindamycin
* Tablets: 300 mg PO b.i.d. × 7 days
* Vaginal suppositories 100 g intravaginally QHS × 3 days
* Bioadhesive cream 2%: 5 g × 1 dose
* During therapy with metronidazole, **alcohol should not be consumed**
84
**Greenish gray** frothy vaginal discharge with mild itching
Trichomonas
85
Hallmark pelvic exam finding in 20% of trichomonas infections is petechiae on the cervix (also known as a "**strawberry cervix**")
Trichomonas
86
Dx of trichomonas
The presence of **mobile and pear-shaped protozoa with flagella** on wet mount
87
Tx of trichomonas
**Metronidazole** 2 g PO x 1 dose
* Sexually transmitted; therefore, the **partner must also be treated**
88
Irritation, dryness, **painful intercourse**, increased UTIs, urinary incontinence; **Recurrent UTI despite treatment**
Atrophic vaginitis
89
Dx of atrophic vaginitis
Can diagnose on **vaginal exam** – thin, pale appearing mucosa – diagnosis of exclusion in postmenopausal women
90
Tx of atrophic vaginitis
with topical estrogen creams ([View full treatment guidelines](https://drive.google.com/file/d/1sY5ZhJPT_FRAiHsDQbOisUwezfYBwn06wbK5LE_iYs0xkK8nQjrlM7UvniOOwR4VoVQiSjBDASK7BM03/view?usp=sharing))
* **Conjugated estrogens vaginal cream** (0.625 mg/g) 0.5–2 g vaginally daily for three weeks, then tapered to lowest effective dose twice weekly; administer cyclically (3 weeks on, one week off)
* Can give oral HRT if no contraindication
* Non-hormonal vaginal moisturizers
