Mrs. M, a 58-year-old woman comes to your office as a new patient with a primary complaint of vaginal discharge. 

Mrs. M is well groomed, communicates well, and works in central processing at a neighboring hospital. She was diagnosed with breast cancer three years ago and has been receiving tamoxifen therapy following her lumpectomy. She has been repeatedly treated for a yeast infection by her primary-care provider, but says the symptoms have not improved. She is going through a divorce and has not had sexual intercourse for “almost a year.”

Mrs. M’s vital signs on physical examination:  BP 130/70mm Hg; pulse 84bpm. She is 5′ 7” tall and weighs 160lbs. Her last menstrual period was at age 50. 

On physical examination:

            Vulva: Normal, no lesions

            Vagina: Moderate green/yellow discharge, erythematous vaginal epithelium; atrophic changes

            Wet prep: WBCs; no yeast forms noted

            Cervix: Petechiae

            Uterus: Small, AV, non-tender, mobile

            Adnexa: Small ovaries palpable consistent with menopause

Based on the findings, Mrs. M may have atrophic vaginitis or possible infectious vaginitis. A vaginal culture should be obtained to rule out a sexually transmitted infection and noninfectious organisms (yeast, bacteria). A vaginal moisturizer should be recommended, as Mrs. M is not a candidate for local estrogen therapy if diagnosed with atrophic vaginitis (per breast surgeon/oncologist). Patient education should be provided regarding estrogen loss and vaginal health.