1- Menopause and Pelvic Organ Prolapse Flashcards
How is menopause defined?
Permanent cessation of menses for 12 consecutive months
How long before the FMP (final menstrual period) does perimenopause (aka menopausal transition) begin?
~4 years
In which stage of menopause does ovarian estrogen fluctuate unpredictably?
Perimenopause (menopausal transition)
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?
Perimenopause (menopausal transition)
Also not necessary for dx of perimenopause, what lab values are suggestive of this phase?
FSH > 25
What is the median age of menopause/ what age is considered abn?
Median age = 51.5
Abn = before 40
What is the most common cause of abnormal menopause (before age 40)?
Primary ovarian insufficiency
What lab value is diagnostic for menopause?
FSH > 70
(typically found in post-menopausal women)
When do vasomotor sxs a/w menopause typically resolve?
Stop spontaneously w/i 4-5 yrs of onset
What stage of menopause is a/w with vasomotor sxs, vaginal dryness, increased risk of osteoporosis, CV disease, dimentia, and mood sxs?
Postmenopause
What is defined as a sudden sensation of extreme heat in the upper body (particularly face, neck, chest) and what is the cause?
Hot flush, due to narrowing of thermoregulatory zone
What is the treatment for vasomotor sxs? (5)
Lifestyle mod, hormone therapy, SSRIs/ SSNRIs, Clonidine, Gabapentin
What treatments are not recommended for vasomotor sxs?
Progestin-only meds, testosterone, compounded bioidentical hormones
What is considered the most effective therapy for vasomotor sxs, resulting in a 65% reduction in weekly hot flush frequency?
Systemic hormone therapy
Pt undergoing menopause with vasomotor sxs and hx of hysterectomy. What hormone therapy do you treat with?
Estrogen only
Pt undergoing menopause with vasomotor sxs and intact uterus. What hormone therapy do you treat with?
Combined E + P
Why should women who still have a uterus NOT be treated with/ use unopposed E?
Endometrial hyperplasia and increased risk of endometrial adenocarcinoma
What are the SEs of systemic hormone therapy in the treatment of vasomotor sxs?
Breast tenderness, vaginal bleeding, bloating, HAs
How should hormone therapy be dosed for the treatment of vasomotor sxs?
Lowest effective dose for shortest duration needed
Generally not > 5 yrs or beyond 60 yo
What are the risks a/w HT (hormone therapy)?
Thromboembolic disease and breast CA
What HT results in slightly increased risk of breast CA, CHD, stroke, and venous thromboembolic events but decreased risk of fractures and colon CA?
Combined HT
What HT results in increased risk of thromboembolic events but no increased risk of CV events of breast CA?
Estrogen only
Does transdermal E or oral E have a lower risk of venous thromboembolism?
Transdermal E
What are the c/i to HT in the treatment of vasomotor sxs? (7)
- Breast CA
- CHD
- Previous venous thromboembolic event/ stroke
- Active liver disease
- Unexplained vaginal bleeding
- High-risk endometrial CA
- Transient ischemic attack
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?
Progestin alone
(add-on to E)
Why is progestin alone not considered a first-line therapy for the management of vasomotor sxs?
Risk of breast CA
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?
Improves sexual function for postmenopausal women
What is the concern with compounded preparations for hormone therapy? (3)
Purity, potency, quality
(also expensive if salivary hormone level testing recommended)
What non-hormonal meds are used in the tx of vasomotor sxs?
SSRIs (only one FDA approved for hot flashes), SRNIs, antiepileptics/ centrally-acting
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)
Phytoestrogens, herbal remedies, vit E, accupuncture
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?
Genitourinary syndrome of menopause
What is a/w vaginal dryness, itching, dyspareunia, and sexual dysfunction?
Vulvovaginal atrophy
In addition to vulvovaginal atrophy, what other genitourinary sxs are associated with menopause?
Urinary frequency and recurrent bladder infections
What are options for management of vulvovaginal atrophy?
Water-soluble moisturizers/ lubricants, HT
What type of HT is preferred when therapy is solely used to treat vulvovaginal atrophy?
Local estrogen
What treatment should be considered for vulvovaginal atrophy in women with a hx of breast CA?
Non-hormonal treatments (theoretical risk of E tx if hx of hormone sensitive breast CA)
What are the options for HT of vulvovaginal atrophy?
Estrogen, SERMS (Ospemifene)
With osteoporosis, low bone mass, microarchitectural disruption, and skeletal fragility lead to what?
Decreased bone strength and increased fracture risk
What are the 2 biggest clinical RFs for osteoporosis?
Advanced age, female sex
(others: white/ Asian, long-term glucocorticoids, low body weight, excess EtOH intake, tobacco, FH, vit D def)
How much daily calcium and vit D is recommended if 9-18 yo?
1300 mg Ca, 600 IU vit D
How much daily calcium and vit D is recommended if 19-50 yo?
1000mg Ca, 600 IU vit D
How much daily calcium and vit D is recommended if 51-70 yo?
1200 mg Ca, 600 IU vit D
How much daily calcium and vit D is recommended if > 71 yo?
1200 mg Ca, 800 IU vit D
What are the 2 methods for diagnosing osteoporosis?
DEXA
Fragility fracture @ spine, hip, wrist, humerus, rib, pelvis
How are results of a DEXA expressed?
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)
What T-score on DEXA is considered normal?
≥ -1.0
What T-score on DEXA is considered low bone mass (osteopenia)?
Between -1.0 and -2.5
What T-score on DEXA is considered osteoporosis?
≤ -2.5
When does screening for osteoporosis begin?
By age 65 for normal, healthy women (earlier if postmenopausal w/ RFs)
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
Earlier screening necessary for osteoporosis
Who are candidates for osteoporosis therapy? (3)
- 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
What is initial/ first line for osteoporosis therapy?
Bisphosphonates (reduce bone resorption and turnover)
Aside from bisphosphonates (1st line), what other pharmacologic therapies are used in the tx of osteoporosis?
- 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
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?
Repeat in 5-15 yrs
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?
Repeat in 1 year
With respect to osteoporosis monitoring, if pt is found to have osteoporosis and on treatment, when should they get their next DEXA?
Repeat in 1-2 yrs and 2 yrs thereafter
How is pelvic organ prolapse defined?
Descent of 1+ aspects of the vagina or uterus
What are the types of pelvic organ prolapse?
Apical (uterovaginal, vaginal vault- enterocele)
Anterior compartment (cytocele)
Posterior compartment (rectocele)
Procidentia
When is pelvic organ prolapse considered a problem?
If having sxs
(sxs: bulge/ something falling outside of vagina, heaviness, pressure, discomfort, urinary sxs, defecatory sxs, splinting, pain/ irritation)
What is the difference between apical uterovaginal and apical vaginal vault prolapse?
Presence of a uterus
What structure descends in anterior compartment (cytocele) prolapse?
Bladder
What structure descends in posterior compartment (rectocele) prolapse?
Rectum
What is procidentia?
Severe form of pelvic organ prolapse
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)
Pelvic organ prolapse
Prior prolapse surgery is a RF for what?
Recurrent prolapse
In addition to gynecologic exam, what else should be performed as part of the PE for POP?
Neurologic exam (voluntary muscle control, pelvic floor reflexes)
Aside from expecant management (reassurance), what is included as part of conservative management for POP?
Pessary, pelvic floor muscle exercises
When should surgical treatment be considered for the treatment of POP?
Symptomatic prolapse who failed or declined conservative management
What are the 2 types of pessaries used in management of POP?
Support pessaries and space-filling pessaries
Pessaries are typically considered safe and effectively. What are their more common disadvantages?
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)
What is the general goal of surgical treatment for POP?
- Provide apical support
- Sacrocolpopexy- correct all compartments
- Plication (folding) of vaginal tissue to reduce bulging
What is the disadvantage to obliterative procedures in the management of POP?
No longer able to have intercourse
Although POP is almost never urgent/ emergent, what are the exceptions?
Urinary retention or obstructive nephropathy
(place indwelling cather and urogyn consult)
