17: 55-year-old post-menopausal woman with vaginal bleeding Flashcards
Definition of Menopause
Menopause is a normal process that occurs as the ovaries are depleted of follicles and produce less estrogen. It is thought to be, primarily, the lack of estrogen that leads to the majority of postmenopausal symptoms.
This happens in the US at a median age of 52 years, between 40 and 58 years of age for most women.
The natural process leading up to menopause may take several years. During the transition, it can be difficult to make a firm diagnosis. National guidelines define menopause as 12 months without a cycle.
Symptoms of Menopause
Hot flashes or vasomotor symptoms are the most common symptoms of menopause, and are present in up to 80% of menopausal patients.
Many women will also experience symptoms of atrophic vaginitis, which can lead to vaginal dryness and dyspareunia (pain during intercourse) and urinary symptoms.
Since menopause can be associated with a variety of additional problems including sexual dysfunction, sleep disturbance, mood disturbance, and concentration difficulties, it can significantly affect a woman’s daily functioning and quality of life.
Initial History for Vaginal Bleeding in Postmenopausal Woman
Detailed description of recent bleeding and any associated symptoms.
Last menstrual period.
Other gynecological problems or bleeding problems.
Family history of cancer, bleeding problems, or female problems.
Detailed medication history, including as-needed medications and/or supplements. Review health maintenance.
Mammogram
There are some conflicting recommendations for breast cancer screening at this time: U.S. Preventive Service Task Force (USPSTF)
Recommends biennal screening mammography for women aged 50-74 and that starting screening mammography prior to 50 years of age should be a decision that is individualized for each patient. (They found insufficient evidence to assess the benefits and harms for women over age 75.)
»The American College of Obstetricians and Gynecologists and the American Cancer Society
Recommend annual screening mammography for women beginning at age 40.
Clearly, it is important to use a shared decision-making process with women to individualize these recommendations with a discussion of risk and benefits for them personally. Between the ages of 40 and 50, calculating the women’s risk factor a risk calculator would be helpful in individualizing recommendations.
Colon cancer screening
Colon cancer screening is recommended for everyone over the age of 50 continuing until the age of 75. There are various ways to screen, including:
Stool-based tests: Usually performed annually. Guaic-based fecal occult blood tests (gFOBT) are a bit less convenient than fecal immunochemical tests (FIT) as they require collecting three samples, whereas FIT only require one sample. Studies have found FIT testing more sensitive than gFOBT testing for colorectal cancer and adenomas. Any positive stool-based screen must be evaluated with a more definitive test, usually a colonoscopy.
Colonoscopy: Allows for a biopsy. Is often utilized especially if the patient has a family history of colon cancer, a change in bowel habits, or any reported rectal bleeding.
Pap smear
Regular screening with Pap smears (cytology) has been very effective at reducing mortality from cervical cancer in screened populations. Extensive research and newer technologies have allowed for more precise guidelines for cervical cancer screening in patients of average risk. Recent recommendations from the American Society for Colposcopy and Cervical Pathology call for Pap smear screening to start at age 21 and continue every three years until age 30. Preferred screening from age 30-65 is with HPV testing in addition to the cytology test (Pap) every five years. Screening this age group (30-65) with cytology alone every three years is an acceptable alternative.
For women with possible gynecologic pathology or certain risk factors - such as HIV, immunosuppression, DES exposure (while in utero), or history of cervical cancer - more frequent Pap smears may be indicated. These guidelines do not currently prohibit testing more often if the physician feels it is indicated, or if the patient requests more frequent screening. However, insurance coverage for more frequent tests in average risk patients will likely end once these new guidelines are accepted.
Screening Not Indicated for Women in Their 50’s Without Risk Factors
Osteoporosis
Osteoporosis screening is recommended by the USPSTF for all women at, or over the age of 65, and in younger women who have equivalent fracture risks to the average white woman at age 65.
CA-125 level
CA-125 is not indicated as a screening tool for ovarian cancer by the USPSTF. This is supported by evidence that although it may detect ovarian cancer at an earlier stage, it does not lower mortality rates. In addition, the prevalence of ovarian cancer is low, giving the test a low positive predictive value, which makes this a poor screening tool.
Physical Examination for Abnormal Uterine Bleeding
Pelvic Exam: Look for vulvar or vaginal lesions, signs of trauma, and cervical polyps or dysplasia. On bimanual examination, assess the size and mobility of her uterus, as a firm, fixed uterus would be concerning for uterine cancer.
Neck Exam: Thyroid exam to look for goiter or nodules, as thyroid disease is one of several systemic diseases that can cause dysfunctional uterine bleeding.
Skin Exam: Look for evidence of bleeding disorders, like bruises. Also, jaundice on skin exam and hepatomegaly on abdominal exam might signify an underlying acquired coagulopathy via liver disease.
Symptoms & Findings of Atrophic Vaginitis
Symptoms: Vaginal dryness, dyspareunia, urinary symptoms and vaginal pruritis.
»Urinary symptoms: Recurrent urinary tract infections, urinary frequency, and dysuria. Local estrogen may help women with urge incontinence and recurrent urinary tract infections. We’re not sure if estrogen helps with overactive bladder, and there is conflicting evidence about its effect on stress incontinence.
»Vaginal pruritis: Local symptoms are usually best treated with topical estrogen in the form of either a vaginal cream or an estrogen ring, which is an estrogen impregnated ring inserted into the vagina.
Physical exam findings:Smoother vaginal mucosa and cervix, related to postmenopausal changes from decreased estrogen levels.
The following increase the amount of unopposed estrogen and thereby increase the risk for endometrial cancer:
unopposed estrogen therapy tamoxifen (Nolvadex) - Often used in women with breast cancer and has an estrogenic effect on the female genital tract. obesity anovulatory cycles estrogen-secreting neoplasms early menarche (before age 12) late menopause (after age 52) menstrual cycle irregularities nulliparity
Risk Factors for Endometrial Cancer
Conversely, smoking seems to decrease estrogen exposure, thereby decreasing the cancer risk, and oral contraceptive use increases progestin levels, thus providing protection.
Other risk factors for endometrial cancer include: hypertension, diabetes, and breast or colon cancer.
Age is also a risk factor for endometrial cancer: The incidence of endometrial cancer more than doubles from 2.8 cases per 100,000 in those aged 30 to 34 years to 6.1 cases per 100,000 in those aged 35 to 39 years. Thus, the American College of Obstetricians and Gynecologists recommends endometrial evaluation in women aged 35 years and older who have abnormal uterine bleeding.
When to Screen for Osteoporosis
United States Preventive Services Task Force recommends osteoporosis screening for all women over the age of 65 and for younger women who have an equivalent risk to the average 65-year-old white female (9.3% ten-year risk of any osteoporotic fracture as calculated by the FRAX score).
The World Health Organization has developed a tool to calculate the risk of fracture, the FRAX, which may be helpful in evaluating individual patients. The tool adjusts for gender, ethnicity, and locale.
While the USPSTF found insufficient evidence to recommend screening in men, the FRAX includes calculations for men and may provide useful information about their fracture risk.
Osteoporosis Risk Factors
> > Corticosteroid use
Family history of osteoporosis, especially if a first-degree relative has fractured a hip.
Previous fragility fracture defined as a low-impact fracture
Smoking
Heavy alcohol use
Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density. Obesity (B) does not put patients at risk for osteoporosis, but neither is obesity protective against osteoporosis.
Caucasian race - At any given age, African-American women on average have higher bone mineral density (BMD) than white women. The USPSTF, while acknowledging that the data for non-white women is less compelling than for whites, recommends screening all women at age 65 or earlier if they have equivalent risk.
Strategies to Prevent Osteoporosis
Most women over 50 should consume an average of 1200 mg of calcium and 800 to 1,000 IU of vitamin D daily
DEXA scan
a bone densitometry study that usually looks at the lumbar spine and hip density to determine if someone has osteoporosis. This is done based on a T-score. A T-score of -1.0 to -2.5 is consistent with decreased bone density or osteopenia. Osteopenia is not a clinical diagnosis and just indicates the degree of bone decline since peak bone mass. It is usually not an indication for treatment aside from lifestyle. A T-score of less than -2.5 indicates osteoporosis. Based on the patient’s risk for fracture and their T-score, we can then make recommendations for treatment of osteoporosis.
The T-Score is a statistical measure that compares one person’s bone mass density (BMD) in standard deviations to the average peak bone mass density in a young healthy person. A zero value is the average BMD for a young healthy person and the T-Score is then the number of standard deviations from that mean. For instance, a T-score of -1.0 indicates a bone density that is one standard deviation below the BMD of a young healthy person. This statistic is then used to classify the BMD of an individual into normal (0 to -1), osteopenia (-1 to -2.5) and osteoporosis (below -2.5).
