Mrs. B, a 53-year-old G2P2 comes in for her annual visit. Her medical history is significant for DCIS (ductal carcinoma in situ) Stage 1 of the right breast five years ago. 

Mrs. B had a right mastectomy with node resection followed by chemotherapy and reconstructive surgery.  She remains disease free, has routine mammography and follow-up with her oncologist. She reports no significant interval history since her annual exam last year. All of her pap tests have been negative, and she has had one sexual partner, her husband, to whom she has been married for 31 years.

Mrs. B is a well groomed and conversant Caucasian woman. She is 5’6″ tall and weighs 145lbs. Vital signs on physical examination were good: BP 120/76mmg Hg; pulse 80bpm.

On physical examination:
HEENT: normal, no adenopathy
Chest: Heart RRR, normal respirations
Breast: Right reconstruction – no masses/adenopathy; left breast normal – no adenopathy
Abdomen: Soft, + BS all four quadrants
External genitalia: Normal, slight vulvar ecchymosis and thinning pubic hair
Vagina: Atrophic changes
Cervix: Parous normal; pap deferred
Bimanual exam: Uterus small, adnexa negative for masses, ovaries non-palpable
Rectal: Negative for occult blood, confirms bimanual
DEXA  bone density scan: Osteoporosis revealed at lumbar spine (T score -2.5); hip (T score -2.0)

Normal exam; personal history of breast cancer: five-year survivor; atrophic vaginitis. Osteoporosis.

Discuss with Mrs. B atrophic vaginitis options including vaginal moisturizer and oil, recommended as sexual lubricant. Contact her oncologist to discuss the risks and benefits of using local vaginal estrogen. To treat Mrs. B’s osteoporosis, raloxifene (Evista; Lilly) is recommended due to her history of breast cancer. Findings from the STAR (Study of Tamoxifen and Raloxifene) trial support the drug’s indications for breast cancer risk reduction and the prevention and treatment of osteoporosis.