Common Genitourinary Symptoms in Midlife Women

Question 1

GSM

Answer 1

-collection of s/sxs a/w estro deficiency that lead to change in labia, introitus, vagina, clitoris, bladder, & urethra that must be bothersome to the woman & not caused by another dx
-VVA is a component of GSM
-chronic & progressive condition
-sxs are unlikely to improve wo tx

Question 2

S/Sxs of GSM

Answer 2

-loss of elasticity
-shortening of vaginal vault
-narrowing of the introitus
-loss of vaginal rugae
-diminished blood flow
-thinning of vaginal tissue
-mucosal changes:
>petechiae, pallor, microfissures
>dryness
>irritation
>burning
>soreness
>tightness
>frequent/recurring UTIs
>lack of moisture w sexual activity
>dyspareunia

Question 3

Evaluation of GSM

Answer 3

-complete med hx: sxs characterization, prior tx, review of vaginal irritants
-sexual hx
-PE: vaginal pH, wet prep as indicated, vulvar/vaginal cxs as appropriate, bx white, pigmented, or thickened lesions
-any vulvar lesion that does not response to tx should be bx’d

Question 4

Prevalence of GSM

Answer 4

-more than 50M US women +52yo
-20-84% of meno women are affected by VVA
-about half of sexually active meno women experience bothersome sxs of GSM/VVA
-meno women w sexual dysfunction are 4x more likely to have VVA sxs
-most sxs are vaginal dryness & dyspareunia
-negatively affects sexual intimacy & QOL

Question 5

Other Causes of GSM

Answer 5

-conditions resulting in low estrogen state:
>prolonged lactation, hypothalamic amenorrhea, POI, tx w gonadotropin-release hormone agonists/antagonists, ovarian surgery, chemotherapy, pelvic radiation, tx w aromatase inhibitors

Question 6

Tx for GSM: Nonhormone therapies

Answer 6

-vulvovaginal moisturizers
-vulvovaginal lubricants
-PFPT
-vaginal dilators
-regular vulvovaginal stimulation
-penetrative sexual activity
-topical lidocaine
-fractional laser (not a lot of support)

Question 7

Tx for GSM: Lubricants & Moisturizers

Answer 7

-Lubricants: water-based, silicone-based, oil-based
-moisturizers: last longer

Question 8

Tx for GSM: Vaginal & Pelvic Floor Activity

Answer 8

-regular stimulation of the vulva & vagina promote blood flow to genital area & natural secretions help maintain vaginal health
-penetrative sexual activity w/wo partner may help maintain vaginal width, length, & tone
-severe GSM may require PFPT & vaginal dilators to treat provoked pelvic floor hypertonus in combo w pharmaco interventions to treat atrophic epithelial changes for optimal outcomes

Question 9

Tx for GSM: Fractional CO2 Laser

Answer 9

-laser therapy helps w vaginal laxity & incontinence therapy - still controversial
-not FDA-approved for tx of GSM
-some studies show benefit of 3 treatments (6 wks apart)
-vaginal sxs & sexual function scores increased by 3mo, w some continued improvement at 1yr
-trials comparing laser vs vaginal ET still ongoing
-more studies needed d/t expensive technology & unknown long-term effects

Question 10

Tx for GSM: HT

Answer 10

-for moderate to severe sxs & those who do not respond to lubricants/moisturizers
>low-dose vaginal ET
>vaginal DHEA
>ospemifene
>systemic ET (when VMS are also present)

Question 11

HT: Low-dose Vaginal Estrogen

Answer 11

-restores vaginal blood flow, decr vaginal pH, improves thickness & elasticity of vulvovaginal tissues
-different forms: ring, tablets, creams
-improves w/in a few weeks, w full efficacy in 2-3 mo
-serum levels typically in postmeno range
-large study show no increased risk of endometrial ca, breast ca, CVD
-addition of progestogen not indicated
-obese women incr risk of endometrial ca, endometrial surveillance or intermittent progestogen w/drawal might be considered
-any vaginal bleeding should be evaluated

Question 12

HT: DHEA

Answer 12

-dehydroepiandosterone
-0.5%/6.5mg DHEA vaginal suppository
-FDA approved for moderate to severe dyspareunia 2/2 VVA
-insert qD at HS
-phase 3 study showed significant improvement of: vaginal maturation index (VMI), vaginal pH, signs of atrophy, vaginal dryness, dyspareunia
-serum steroid levels remained w/in the normal postmeno range
-AE: vaginal discharge bc of melting suppository
-Safety: endometrial safety confirmed at 1y

Question 13

HT: Ospemifene

Answer 13

-selective estrogen receptor modulator: estrogen agonist/antagonist
-FDA approved for moderate to severe dyspareunia a/w VVA
-daily oral admin (60mg)
-improves: VMI, vaginal pH, symptoms of VVA
-Safety: no endometrial hyperplasia or cancer (at 52 wks); can increase VMS, may incr risk of VTE
-antiestrogenic effects on breast but not approved for women w breast ca
-favorable effects on bone

Question 14

Other Vulvar & Vaginal Sxs

Answer 14

-conditions other than GSM can cause vulvovaginal sxs in postmeno women
-vulvodynia - vulvar pain of at least 3mo duration wo identifiable cause (dx of exclusion & there are limited RCTs to guide tx)
-vulvovaginitis - caused by candida, BV, STIs, or desquamative inflammatory vaginitis
-dx of vaginitis is made of use pH, saline, KOH microscopy & testing for gonorrhea & chlamydia as indicated; tx is specific to infection

Question 15

Vulvovaginal Conditions

Answer 15

-lichen sclerosus & lichen plan us are chronic inflammatory disease of the vulva that cause severe pruritis & pain
-appears as while plaques & papules or as erosive-appearing ulcerations, sometimes w fissuring
-dx’d by bx & tx is usually w high-potency topical steroid
-various forms of dermatitis, including contact & allergic are common & can be r/t soaps, detergents, other irritating; good vulvar hygiene & reducing irritants help relieve sxs
-lichen simplex chronicus, psoriasis, & seborrheic dermatitis also may affect the vulva

Question 16

Other Vulvovaginal Conditions

Answer 16

-vulvovaginal neoplasias can cause pain &/or itching & include vulval intraepithelial neoplasia (VIN), squamous cell carcinoma, basal cell carcinoma, Paget disease
-VIN classified grades as low, high, differentiated type; low grade = HPV effect, high grade = precancerous
-differentiated type VIN a/w vulvar conditions such as lichen sclerosus, lichen planes, & not HPV related; also a/w vulvar ca
-dx is made by bx & surgical tx is usually needed

Question 17

Vulvar Masses

Answer 17

-condyloma acuminatum is from HPV infection (genital warts)
-tx w topical agents such as trichloroacetic acid, podophyllin, or imiquimod
-extensive recurring cases may require laser or surgery
-sex partners w visible lesions need tx
-less common are hidradenomas, lipomas, fibromas, less commonly syringomas & schwannomas
-large masses may need referral to gyn onc for local wide excision

Question 18

Vulvar Masses (cont)

Answer 18

-epidural inclusion cysts are common, smooth subq nodules that are mobile & nontender; excised if bothersome but otherwise no tx needed
-bartholin gland cysts & abscesses present as swelling in posterior labia Minorca; abscess is tender, cysts are not
-tx of cysts is elective but abscesses should be I&D; consider marsupialization for recurrent abscesses
-bathroom in cysts that occur or enlarge in postmeno should be bx’d

Question 19

UTI

Answer 19

-postmeno may experience recurring UTIs bc of changes in vaginal pH & the microbiome
-RF aging, incontinence, prolapse, increased postvoid residual, type 2 diabetes
-after initial Abe tx, preventative measures may include vaginal estrogen, which restores pH, increases lactobacilli, & improve immune response
-other prevention measures may include hygiene measures, prophylactic abx, cranberry supplements
-women w recurrent UTIs w unusual pathogens should be evaluated for urinary tract abnormalities & urine retention

Question 20

Pelvic Floor disorders

Answer 20

-encompass urinary incontinence, pelvic organ prolapse, anal incontinence, defectors dysfunction
-more common during perimeno & postmeno, it is not normal
-urinary incontinence affects half of older women, so ask about voiding problems
-types of urinary incontinence: stress, overactive, mixed

Question 21

Stress Urinary Incontinence

Answer 21

-loss of urine w activity like coughing or sneezing that incr intrabdomen pressure; linked to poor urethral support, urethral sphincter weakness, pelvic floor dysfunction
-evaluate includes voiding diary, UA, U cx to exclude infxn & bladder pathology; occasionally more specialized testing such as urodynamic studies & cystoscope
-tx options include wt loss, cough suppression, PFPT, pessaries, surgeries to support urethra

Question 22

Overactive Bladder or Urge Incontinence

Answer 22

-loss of urine w the urge to void & a/w overactivity of the detrusor muscle
-tx options include bladder retraining, fluid restriction, improving mobility or toilet access, decreasing bladder irritants such as caffeine, meds such as antimuscarinics
-nerve stimulation techniques & Botox are also used

Question 23

Other types of Incontinence

Answer 23

-mixed incontinence include sxs of both stress & urge
-tx for each component may be indicated to fully resolve sxs
-extraurethral incontinence less common & is d/t abnormal opening of the bladder such as a vesicovaginal fistula

Question 24

Lower Urinary Tract & Pelvic Floor Disorders

Answer 24

-pelvic organ prolapse is essentially herniation of the uterus, bladder, or rectum in to the vagina, & presents as a vaginal bulge or pressure
-RF include aging, parity, obesity, hysterectomy
-tx options include obs if the prolapse is not bothersome, pessaries, surgery specific to the defect
-recurrence rates may be as high as 30%
-prolapse & incontinence frequently coexist, & anal incontinence & functional constipation can occur in women w prolapse

Question 25

Anal Incontinence

Answer 25

-reported by about 9% of community-dwelling women
-defined as loss of anal sphincter control leading to involuntary leakage of gas or stool sufficient to impair QOL
-structural causes include poorly healed tears &/or enervation of the anal sphincter
-functional causes include constipation, diarrhea, IBS, malabsorption syndromes, polyps, hemorrhoids
-many women respond to conservative measures including dietary management, PFPT, but some require sacral nerve stimulation or surgery

Question 26

Defecatory Dysfunction or Functional Constipation

Answer 26

-straining to defecate, incomplete emptying of the rectum, constipation; reported by 27% adults
-caused by outlet obstruction, slow bowel motility, dyssynergic defecation, or maybe idiopathic
-conservative txs incr dietary fiber & fluid
-bulk forming laxatives, surfactants, osmotic agents are preferred over stimulant laxatives
-PFPT also helpful in some cases
-may also help w tx of anal fissures & hemorrhoids