What treatment is recommended for an 81-year-old female with uncontrolled diabetes (hyperglycemia), well-controlled hypertension (on Losartan (losartan)), and dyspareunia, with a history of total hysterectomy and microscopic hematuria?

Management of Dyspareunia in an Elderly Patient with Uncontrolled Diabetes

For an 81-year-old female with dyspareunia and uncontrolled diabetes (A1c 9.1%), intravaginal prasterone therapy is recommended as first-line treatment to address the vaginal symptoms while simultaneously prioritizing glycemic control to reduce A1c to 7.5-8.0%. 1

Assessment of Dyspareunia

The patient's dyspareunia is likely related to:

• Post-menopausal vaginal atrophy (given her age)
• History of total hysterectomy (which can contribute to vaginal shortening and dyspareunia) 2
• Uncontrolled diabetes (which can worsen vaginal symptoms through impaired microcirculation)

The absence of dysuria and negative previous workup for microscopic hematuria (negative CT and cystoscopy) suggests that urinary tract infection is not the cause of her symptoms.

Treatment Plan

1. Address Dyspareunia

• First-line treatment: Intravaginal prasterone (synthetic DHEA) for moderate to severe dyspareunia 1

  • Advantages: Improves vaginal pH and cell counts
  • Does not carry a boxed warning unlike some estrogen therapies
  • Maintains serum hormone levels within normal postmenopausal range
  • FDA-approved specifically for dyspareunia due to vulvar and vaginal atrophy

• Alternative options:

  • Non-hormonal vaginal moisturizers and lubricants
  • Low-dose vaginal estrogen preparations if prasterone is not effective

2. Optimize Diabetes Management

• Target A1c: 7.5-8.0% (appropriate for elderly patient with multiple comorbidities) 3, 4

  • Less stringent target is appropriate due to advanced age and risk of hypoglycemia
  • Current A1c of 9.1% indicates poor control requiring intervention

• Medication recommendations:

  • First-line: Metformin (if not contraindicated by renal function) 3, 4
  • Consider adding:
    • SGLT2 inhibitor (if eGFR >30 mL/min/1.73m²)
    • GLP-1 receptor agonist (particularly if weight loss would be beneficial)
    • Avoid sulfonylureas due to hypoglycemia risk in elderly 4

• Monitoring:

  • Regular blood glucose monitoring
  • Quarterly A1c testing until target achieved
  • Annual screening for diabetic complications (retinopathy, nephropathy)

3. Maintain Current Hypertension Management

• Continue losartan 100 mg daily as hypertension is well-controlled 3
• Monitor for orthostatic hypotension, especially if diabetes medications are adjusted

Important Considerations

Avoid Hypoglycemia

• Elderly patients are at increased risk for hypoglycemia 4
• Hypoglycemia can increase fall risk and cognitive impairment
• Prioritize medications with low hypoglycemia risk

Address Uric Acid Crystals

• The presence of uric acid crystals in urinalysis may indicate:
  • Dehydration (common in poorly controlled diabetes)
  • Potential for uric acid stone formation
• Recommend increased fluid intake
• Consider urine pH testing

Follow-up Plan

• Re-evaluate dyspareunia symptoms after 4-6 weeks of treatment
• Monitor diabetes control with A1c testing in 3 months
• Assess for medication side effects and adherence

Potential Pitfalls to Avoid

1. Overaggressive glycemic control: Targeting A1c <7% in this elderly patient could lead to dangerous hypoglycemia 4

2. Attributing dyspareunia solely to UTI: The uric acid crystals are likely incidental and not the primary cause of her symptoms

3. Ignoring the impact of diabetes on sexual health: Poor glycemic control can worsen vaginal symptoms through impaired microcirculation and increased risk of infections

4. Medication interactions: Be cautious of potential interactions between new diabetes medications and her current losartan therapy

By addressing both the dyspareunia and uncontrolled diabetes simultaneously, this approach prioritizes the patient's quality of life while reducing her risk of diabetes-related complications.