Shawna L. Johnston, MD, FRCSC, Assistant Professor, Department of Obstetrics and Gynecology, Queen's University, Kingston, ON.

Abstract
The population of postmenopausal women in Canada is growing rapidly. It is now estimated that there are more than four million women in Canada over the age of 50. Menopause, hormone replacement and the sequelae of estrogen deprivation will become important foci for health care in this century.

Urogenital aging occurs as a result of estrogen deprivation in menopause and of tissue aging itself. Problems originate from the lower urinary tract (urethra and bladder) and from the vagina. Vaginal complaints include dryness, dyspareunia, discharge and/or bleeding. Estimates of prevalence suggest that 40-50% of postmenopausal women are affected. These symptoms, while not life-threatening, can be extremely uncomfortable and limiting, and can negatively impact on quality of life.

Estrogen replacement therapy has long been the mainstay of treatment for vaginal atrophy. Both oral and vaginal estrogen are effective, though the vaginal route is often chosen because it avoids the enterohepatic circulation and can therefore be given in much lower doses. Estrogen can be administered vaginally as a cream. Newer methods of delivery include estradiol vaginal tablets and sustained release intravaginal estradiol rings. Effective nonhormonal alternatives include the vaginal moisturizer, polycarbophil.

One of the most moving speeches I have ever heard was given several years ago at the annual meeting of the American Geriatrics Society. Dr. Masters, a distinguished researcher in the field of human sexuality, was being honoured for his many contributions. Masters pioneered the concept that the human need for intimacy did not disappear at some arbitrary age, but rather was a lifetime need. He expressed very clearly the only two requirements for continuing sexuality in old age: a reasonable state of general health, and availability of a suitable partner. He also stressed that sexuality was not limited to sexual intercourse, and that the presence of erectile dysfunction (then still called impotence) did not necessarily mean the end of all sexual intimacy.

Fortunately, there is now a much better appreciation of the fact that older persons can remain sexually active. It makes as much sense to assume that after a certain age people no longer need to eat! One of the interesting by-products of the research started by Dr. Masters is our understanding of the many medical conditions that can contribute to sexual dysfunction, particularly erectile dysfunction. When I was in medical school, we were taught that, in the absence of severe neurological impairment (e.g., paraplegia), most causes of erectile dysfunction (ED) were psychological in origin. We now understand that medical disorders are the root cause of many cases of ED. In his excellent review of ED, Dr. Peter Pommerville provides the knowledge and tools a primary care physician requires for evaluating an older man with this condition. As well, Dr. Roland Tremblay discusses the emerging concept of andropause, its diagnosis and possible therapeutic strategies.

Of course, men are only half of the sexual intimacy story. Women also have a need for sexual intimacy, and the two principles that Dr. Masters championed (reasonable general health, availability of a suitable partner) apply to both men and women. However, the issues do differ between the sexes, and we have a trio of articles that pertain specifically to women. Dr. Stephen Holzapfel discusses the physical and mental aspects of maintaining sexual health in older women. Dr. Scott Farrell discusses the broad topic of urogenital health in elderly women, while Dr. Shawna Johnston focuses on the recognition and management of a common problem in older women, atrophic vaginitis.

Regular readers of this journal already know that geriatric medicine differs from practice in younger adults for a variety of reasons (atypical presentation, iatrogenesis, presentation with geriatric syndromes, multiple comorbidity, etc.). One major difference when performing a physical examination of an older person is that the neurological examination is usually required to understand the patient's problems, even when the presentation is not primarily neurological. Dr. David Gladstone and Dr. Sandra Black discuss the approach to the neurological exam in normal aging and in diseases common in the elderly. In a complementary article, Dr. Daniel Silverman discusses neuronuclear imaging in the evaluation of early dementia.

As usual, we have a potpourri of other articles, including Dr. Arthur Bookman's discussion of new advances in the treatment of rheumatoid arthritis, and Dr. Ali Ahmed's review of digoxin in older adults with heart failure.

Enjoy this issue.