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6. Women's Health > 1- Menopause and Pelvic Organ Prolapse > Flashcards

1- Menopause and Pelvic Organ Prolapse Flashcards

1
Q

How is menopause defined?

A

Permanent cessation of menses for 12 consecutive months

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2
Q

How long before the FMP (final menstrual period) does perimenopause (aka menopausal transition) begin?

A

~4 years

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3
Q

In which stage of menopause does ovarian estrogen fluctuate unpredictably?

A

Perimenopause (menopausal transition)

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4
Q

Pt presents with irregular menses, hot flashes, night sweats, mood sxs, vaginal dryness, and changes in lipids and bone loss. What are you concerned for?

A

Perimenopause (menopausal transition)

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5
Q

Also not necessary for dx of perimenopause, what lab values are suggestive of this phase?

A

FSH > 25

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6
Q

What is the median age of menopause/ what age is considered abn?

A

Median age = 51.5

Abn = before 40

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7
Q

What is the most common cause of abnormal menopause (before age 40)?

A

Primary ovarian insufficiency

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8
Q

What lab value is diagnostic for menopause?

A

FSH > 70

(typically found in post-menopausal women)

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9
Q

When do vasomotor sxs a/w menopause typically resolve?

A

Stop spontaneously w/i 4-5 yrs of onset

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10
Q

What stage of menopause is a/w with vasomotor sxs, vaginal dryness, increased risk of osteoporosis, CV disease, dimentia, and mood sxs?

A

Postmenopause

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11
Q

What is defined as a sudden sensation of extreme heat in the upper body (particularly face, neck, chest) and what is the cause?

A

Hot flush, due to narrowing of thermoregulatory zone

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12
Q

What is the treatment for vasomotor sxs? (5)

A

Lifestyle mod, hormone therapy, SSRIs/ SSNRIs, Clonidine, Gabapentin

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13
Q

What treatments are not recommended for vasomotor sxs?

A

Progestin-only meds, testosterone, compounded bioidentical hormones

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14
Q

What is considered the most effective therapy for vasomotor sxs, resulting in a 65% reduction in weekly hot flush frequency?

A

Systemic hormone therapy

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15
Q

Pt undergoing menopause with vasomotor sxs and hx of hysterectomy. What hormone therapy do you treat with?

A

Estrogen only

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16
Q

Pt undergoing menopause with vasomotor sxs and intact uterus. What hormone therapy do you treat with?

A

Combined E + P

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17
Q

Why should women who still have a uterus NOT be treated with/ use unopposed E?

A

Endometrial hyperplasia and increased risk of endometrial adenocarcinoma

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18
Q

What are the SEs of systemic hormone therapy in the treatment of vasomotor sxs?

A

Breast tenderness, vaginal bleeding, bloating, HAs

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19
Q

How should hormone therapy be dosed for the treatment of vasomotor sxs?

A

Lowest effective dose for shortest duration needed

Generally not > 5 yrs or beyond 60 yo

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20
Q

What are the risks a/w HT (hormone therapy)?

A

Thromboembolic disease and breast CA

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21
Q

What HT results in slightly increased risk of breast CA, CHD, stroke, and venous thromboembolic events but decreased risk of fractures and colon CA?

A

Combined HT

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22
Q

What HT results in increased risk of thromboembolic events but no increased risk of CV events of breast CA?

A

Estrogen only

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23
Q

Does transdermal E or oral E have a lower risk of venous thromboembolism?

A

Transdermal E

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24
Q

What are the c/i to HT in the treatment of vasomotor sxs? (7)

A
  • Breast CA
  • CHD
  • Previous venous thromboembolic event/ stroke
  • Active liver disease
  • Unexplained vaginal bleeding
  • High-risk endometrial CA
  • Transient ischemic attack
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25
Q

What type of HT in the tx of vasomotor sxs is primarily used as an add-on agent to prevent endometrial hyperplasia and endometrial CA in women w/ a uterus?

A

Progestin alone

(add-on to E)

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26
Q

Why is progestin alone not considered a first-line therapy for the management of vasomotor sxs?

A

Risk of breast CA

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27
Q

Testosterone provides no benefit for vasomotor sxs and has potential adverse effects (effect on lipid parameters, clitoromegaly, hirsutism, acne), but what is the benefit of it?

A

Improves sexual function for postmenopausal women

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28
Q

What is the concern with compounded preparations for hormone therapy? (3)

A

Purity, potency, quality

(also expensive if salivary hormone level testing recommended)

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29
Q

What non-hormonal meds are used in the tx of vasomotor sxs?

A

SSRIs (only one FDA approved for hot flashes), SRNIs, antiepileptics/ centrally-acting

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30
Q

Although data is limitied and there is no clear evidence of their efficacy, what things are included in complementary/ alternative therapies for the treatment of vasomotor sxs? (4)

A

Phytoestrogens, herbal remedies, vit E, accupuncture

31
Q

What term encompasses all of the atrophic sxs women may have in the vulvovaginal and bladder-urethral areas from loss of estrogen that occur with menopause?

A

Genitourinary syndrome of menopause

32
Q

What is a/w vaginal dryness, itching, dyspareunia, and sexual dysfunction?

A

Vulvovaginal atrophy

33
Q

In addition to vulvovaginal atrophy, what other genitourinary sxs are associated with menopause?

A

Urinary frequency and recurrent bladder infections

34
Q

What are options for management of vulvovaginal atrophy?

A

Water-soluble moisturizers/ lubricants, HT

35
Q

What type of HT is preferred when therapy is solely used to treat vulvovaginal atrophy?

A

Local estrogen

36
Q

What treatment should be considered for vulvovaginal atrophy in women with a hx of breast CA?

A

Non-hormonal treatments (theoretical risk of E tx if hx of hormone sensitive breast CA)

37
Q

What are the options for HT of vulvovaginal atrophy?

A

Estrogen, SERMS (Ospemifene)

38
Q

With osteoporosis, low bone mass, microarchitectural disruption, and skeletal fragility lead to what?

A

Decreased bone strength and increased fracture risk

39
Q

What are the 2 biggest clinical RFs for osteoporosis?

A

Advanced age, female sex

(others: white/ Asian, long-term glucocorticoids, low body weight, excess EtOH intake, tobacco, FH, vit D def)

40
Q

How much daily calcium and vit D is recommended if 9-18 yo?

A

1300 mg Ca, 600 IU vit D

41
Q

How much daily calcium and vit D is recommended if 19-50 yo?

A

1000mg Ca, 600 IU vit D

42
Q

How much daily calcium and vit D is recommended if 51-70 yo?

A

1200 mg Ca, 600 IU vit D

43
Q

How much daily calcium and vit D is recommended if > 71 yo?

A

1200 mg Ca, 800 IU vit D

44
Q

What are the 2 methods for diagnosing osteoporosis?

A

DEXA

Fragility fracture @ spine, hip, wrist, humerus, rib, pelvis

45
Q

How are results of a DEXA expressed?

A

Expressed in T scores- # of SDs above/ below mean BMD for sex-matched young normal controls

(can also be expressed in Z scores- # of SDs above/ below the mean BMD for women of the same age)

46
Q

What T-score on DEXA is considered normal?

A

≥ -1.0

47
Q

What T-score on DEXA is considered low bone mass (osteopenia)?

A

Between -1.0 and -2.5

48
Q

What T-score on DEXA is considered osteoporosis?

A

≤ -2.5

49
Q

When does screening for osteoporosis begin?

A

By age 65 for normal, healthy women (earlier if postmenopausal w/ RFs)

50
Q

The following are RFs indicating what?

Hx of fragility fracture, body weight < 127 lbs, medical cause of bone loss, parental hx of hip fracture, current smoker, alcoholism, RA, FRAX 10-yr risk of major osteoporotic fracture > 9.3

A

Earlier screening necessary for osteoporosis

51
Q

Who are candidates for osteoporosis therapy? (3)

A
  • Postmenopausal women w/ hx of hip or vertebral fracture
  • Women w T-score ≤ -2.5
  • High-risk postmenopausal women w/ T-scores between -1.0 and -2.5
52
Q

What is initial/ first line for osteoporosis therapy?

A

Bisphosphonates (reduce bone resorption and turnover)

53
Q

Aside from bisphosphonates (1st line), what other pharmacologic therapies are used in the tx of osteoporosis?

A
  • SERMS- inhibits bone resorption and decreased risk of vertebral fracture, reduces breast CA risk
  • Forteo (recombinant PTH)- severe osteoporosis, bisphosphonates c/i’d, refractory
  • Calcitonin- PTH antagonist, less preferred, short-term tx of acute pain relief
54
Q

With respect to osteoporosis monitoring, if pt is found to have normal BMD (T score of 0 to -1.5), when should they get their next DEXA?

A

Repeat in 5-15 yrs

55
Q

With respect to osteoporosis monitoring, if pt is found to have osteopenia (T score of -1.5 to -1.99), when should they get their next DEXA?

A

Repeat in 1 year

56
Q

With respect to osteoporosis monitoring, if pt is found to have osteoporosis and on treatment, when should they get their next DEXA?

A

Repeat in 1-2 yrs and 2 yrs thereafter

57
Q

How is pelvic organ prolapse defined?

A

Descent of 1+ aspects of the vagina or uterus

58
Q

What are the types of pelvic organ prolapse?

A

Apical (uterovaginal, vaginal vault- enterocele)

Anterior compartment (cytocele)

Posterior compartment (rectocele)

Procidentia

59
Q

When is pelvic organ prolapse considered a problem?

A

If having sxs

(sxs: bulge/ something falling outside of vagina, heaviness, pressure, discomfort, urinary sxs, defecatory sxs, splinting, pain/ irritation)

60
Q

What is the difference between apical uterovaginal and apical vaginal vault prolapse?

A

Presence of a uterus

61
Q

What structure descends in anterior compartment (cytocele) prolapse?

A

Bladder

62
Q

What structure descends in posterior compartment (rectocele) prolapse?

A

Rectum

63
Q

What is procidentia?

A

Severe form of pelvic organ prolapse

64
Q

The following are all RFs associated with what condition?

Parity (vaginal deliveries- operative deliveries, birthweight), advancing age, obesity, CT disorders, menopausal status, chronic disease (constipation, COPD)

A

Pelvic organ prolapse

65
Q

Prior prolapse surgery is a RF for what?

A

Recurrent prolapse

66
Q

In addition to gynecologic exam, what else should be performed as part of the PE for POP?

A

Neurologic exam (voluntary muscle control, pelvic floor reflexes)

67
Q

Aside from expecant management (reassurance), what is included as part of conservative management for POP?

A

Pessary, pelvic floor muscle exercises

68
Q

When should surgical treatment be considered for the treatment of POP?

A

Symptomatic prolapse who failed or declined conservative management

69
Q

What are the 2 types of pessaries used in management of POP?

A

Support pessaries and space-filling pessaries

70
Q

Pessaries are typically considered safe and effectively. What are their more common disadvantages?

A

Odor, discharge, vaginal ulcerations, must remove for coitus

(other: rare case reports of erosion into bladder, fistula formation, ureteral obstruction w/ urosepsis/ uremia, SB prolapse and incarceration)

71
Q

What is the general goal of surgical treatment for POP?

A
  • Provide apical support
  • Sacrocolpopexy- correct all compartments
  • Plication (folding) of vaginal tissue to reduce bulging
72
Q

What is the disadvantage to obliterative procedures in the management of POP?

A

No longer able to have intercourse

73
Q

Although POP is almost never urgent/ emergent, what are the exceptions?

A

Urinary retention or obstructive nephropathy

(place indwelling cather and urogyn consult)

6. Women's Health (13 decks)

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