<prompt> Please answer with one of the option in the bracket. Write reasoning in between . Write answer in between .Q:A 54-year-old woman comes to the office complaining of increased urinary frequency and dysuria. She is accompanied by her husband. The patient reports that she goes to the bathroom 6-8 times a day. Additionally, she complains of pain at the end of her urinary stream. She denies fever, abdominal pain, vaginal discharge, or hematuria. Her husband adds, we also dont have sex as much as we used to. The patient reports that even when she is in the mood, sex is no longer pleasurable. She admits feeling guilty about this. The patients last menstrual period was 15 months ago. Her medical history is significant for hyperlipidemia and coronary artery disease. She had a non-ST elevation myocardial infarction NSTEMI 3 months ago, and she has had multiple urinary tract infections UTIs in the past year. She smokes 1 pack of cigarettes a day and denies alcohol or illicit drug use. Body mass index is 32 kgm2. Pelvic examination reveals vaginal dryness and vulvar tissue thinning. A urinalysis is obtained as shown below:UrinalysisGlucose: NegativeWBC: 25hpfBacterial: ManyLeukocyte esterase: PositiveNitrites: PositiveThe patient is prescribed a 5-day course of nitrofurantoin. Which of the following is the most appropriate additional management for the patients symptoms?? A: Antibiotic prophylaxis, B: Combination oral contraceptives, C: Topical clobetasol, D: Topical estrogen, E: Venlafaxine,  <response>: This is a patient case with a multiple choice question asking about the most appropriate additional management for the patients symptoms of increased urinary frequency, dysuria, and painful intercourse. Based on the information provided, the patient is a 54-year-old postmenopausal woman with a history of recurrent UTIs, vaginal dryness, and vulvar thinning on exam. She also has cardiovascular disease. The urinalysis shows evidence of a UTI with many bacteria, leukocytes, and positive nitrites. She has been prescribed nitrofurantoin to treat the acute UTI. The additional symptoms of vaginal dryness and dyspareunia along with vulvar thinning indicate that she likely has vulvovaginal atrophy due to estrogen deficiency in menopause. This can predispose to recurrent UTIs.Choices A and E are not relevant to managing vulvovaginal atrophy. Choice C, topical clobetasol, is a high potency steroid that can have adverse effects with chronic use. Choice D, topical estrogen, is the most appropriate choice to manage the patients vulvovaginal atrophy and related symptoms.D: Topical estrogen 