Common Sxs & Concerns in Midlife Women Flashcards
Decline in fertility w reproductive aging
-age-related decline in fertility starts ~35yo
-pregnancy w woman’s own eggs is rare after 45yo
-mechanisms are age-related depletion of ovarian follicle & older oocytes have higher rate of chromosome abnormalities
-shared decision-making is critical when making contraception choices for women aged >45 y given low chance of pregnancy
>morfe hormone contraception methods mask meno sxs
Sexual function & dysfunction
-important component of perceived qol
-sexual oncerns remain under evaluated & undertreated
-40-50% of women report at least one sex dysfunction —> low desire w distress
-sexual dysfunction a/w decrease in emotional health energy, social function, correlated w relationship conflict & nonspecific medical conditions
Biopsychosocial Model
-effects on female sexual dysfunction
-Physiological: neurological probs, CVD, ca, urogenital disorders, meds, fatigue, hormone loss or abnormality
-Sociocultural influences: limited sex ed, conflict w religious/personal/family values, societal taboos
-Psych/Emotional: anxiety, stress, self-image, depression, hx of abuse/trauma, etoh/substance abuse
-Interpersonal relationships: partner performance & technique, lack of partner, relationship quality/conflict/communication, logistics, lack of privacy
Female Sexual Response Cycle - Basson Model
Cycle:
FSD DSM-IV
-HSDD
-Female Arousal Disorder
-Dyspareunia
-Vaginismus
-Female Orgasmic Disorder
FSD DSM-5
-Female Sexual Interest/Arousal Disorder (FSIAD)
-Genito-Pelvic Pain/Penetration Disorder
-Female Orgasmic Disorder
Neurobiology, Hormones, & Sexual Function
-modulated by a complex interaction between sex steroids & neurotransmitters & influenced by psychosocial factors
-excitatory neurotransmitters & neuropeptides include norepinephrine, oxytocin (stimulates arousal), melanocortins, dopamine (stimulate desire & attention)
-inhibitory pathways regulated by 5-hydroxytryptamine or serotinin (signal satiety), opioids (sexual rewards), and endocannabinoids (cause sedation)
-HSDD caused by an imbalance of excitatory & inhibitory system (greater inhibition than excitation)
-therapies directed at improving imbalance
Screening/Assessment for Sexual Dysfunction
-include sexual history for all midlife women
>Decreased Sexual Desire Screener
>Female Sexual Function Index
>Female Sexual Distress Scale-Revised
>Brief Sexual Symptom Checklist
-Assessment through H&P including pelvic exam; evaluate for meds that may contribute (SSRIs, SNRIs)
-Labs not required for dx for FSD but could r/o other medical conditions that could contribute
-evaluate for pelvic floor dysfunction & refer to PT if needed
Tx for FSD
-Tx is specific to the diagnosis
-Options include psychotherapy, pharmacologic treatments (such as low-dose vaginal estrogen for GSM), vibrator therapy, & PFPT
-flibanserin & bremelanotide - FDA-approved for HSDD in premeno
-off-label testosterone can be considered for postmeno w HSDD
Effects of HT on Sexual Function
-may not improve sexual desire unless vaginal dryness, dyspareunia, or bothersome hot flashes are part of prob
-relationship factors & physical/mental health more important than estrogen levels or menopause status for sexual health
-improves sleep in the setting of VMS, which decreases fatigue
-enhances skin sensation & incr vaginal lubrication & elasticity
Testosterone therapy for HSDD
-incr sexual function (satisfactory sexual event frequency, sexual desire, arousal, orgasm, responsiveness) & self-image & reduces sexual concerns & distress in postmeno
-meta-analyses show no severe AEs w physiological testosterone use
-long-term safety of testosterone therapy not yet established
-total serum testosterone concentration should not be used to dx HSDD
-testo formulations targeting normal premeno physiologic range recommended
-no female testo product is currently approved; compounded testosterone preparations not generally recommended
-male formulations can be judiciously used in female doses w serum testo concentrations monitored regularly
Pelvic floor function
-pelvic floor muscles:
>support urinary, genital, and rectal organs
>provide second postural stabilization of bony pelvis
-pelvic floor muscles = Levator ani muscle groups
>superficial muscles (transverse perineal, bulbospongiosis, ischiocavernosus
>deep muscles (pubococcygeus, iliococcygeus, obturator internus, coccygeus
Pelvic floor dysfunction - low-tone
-pelvic floor muscular support system is functioning abnormally
-low-tone pelvic floor dysfunction (PFD):
>weak, under active, hypotonic muscles that cannot attain or maintain adequate contractions
-sxs:
>incontinence, heaviness, pressure, altered sexual sensation, pelvic organ prolapse
Pelvic floor dysfunction - high-tone
-high-tone PFD
>weak pelvic floor muscles cannot attain or maintain adequate relaxation & are overactive, hypertonic, spastic, shortened
-sxs:
>urinary retention, frequency, urgency, dysruria, fecal retention/constipation, penetrative dyspareunia &/or vaginismus
RF for PFD
-hormone deficiency (menopause state)
>testo & estro receptors present in pelvic floor muscles
>decr or absence of hormones results in decr muscle function & strength and decr blood flow
>develop stiff & weak muscles w restricted ROM
>result: pelvic muscle hypertonus
-trauma:
>hip or back injuries cause incr metabolic activity in upper pelvic stabilizers
>develop pelvic floor muscle spasms
>results in fibrotic muscles w decr flexibility & relaxation
-chronic irritation of pelvic organs:
>from chronic bacterial cystitis, chronic yeast infxns, endometriosis, urethritis, provoked vestibulodynia, or interstitial cystitis
>develop muscular & connective tissue changes & primary muscle skeletal disorders (lumbopelvic or sacroiliac joint dysfunction)
>causes bladder, bowel, & sexual dysfunction
Evaluation of PFD
-complete med hx
-detailed pain assessment
-assess posture, alignment, gait patterns, & movement of spine & hips
-“front-to-back” palpating pelvic floor muscles ->denote local tenderness, shortened muscles, or referred pain patterns
-evaluate pelvic floor muscle coordination ->inability to contract, relax, bulge during exam demonstrates poor coordination of pelvic floor muscles
Tx of PFD: PFPT
-Goals: improve connective tissue mobility, strengthen the core muscles, normalize pelvic tone, deactivate myosfascial trigger points, improve motor control of pelvic floor
-Duration: 30-60 min sessions, 1-2x / wk, 12 wks to 1 yr
Tx of PFD: Muscle Relaxants
-augment muscle relaxation
-oral or compounded topical or trans vaginal
-diazepam, baclofen, cyclobenzaprine, methocarbamol
Tx of PFD: Vaginal Dilators
-cylinder-shaped objctss of smooth plastic, rubber, or glass in a variety of widths/weights
-adjuvant to PFPT
-purpose: stretch the vagina in both width & depth, improve elasticity, stretch pelvic floor muscles, restore vaginal capacity
-technique: chose dilator size that does not cause pain w insertion; show exactly where & how to insert dilator using mirror; apply lube to dilator, insert dilator as far as comfortable, leave dilator in place for 5-10mg x1-2/daily; use each dilator size for 2-4 wks before progressing to a sizes similar to partner size
Tx of PFD: Botulinum A injection
-off-label use in refractory high-tone PFD
-shown to significantly decrease pelvic pain & dyspareunia
-sxs improve demonstrated up to 12wks
-rare complications: local minimal bleeding, hematoma formation, N/V, diplopia, dysphasia, temporary stress urinary incontinence, muscle weakness, &/or urinary retention
-technique: palpate most pain-provoking, hypertonic muscles; injection done via transperineal or transvaginal approach; inject 30-50 units, not exceeding 100-200 total units; reassess at 2-3 wks & 3 mo ; if hypertonus returns, reinvention may be needed
Abnormal uterine bleeding (AUB)
-menses flow outside of normal volume, duration, regularity, or frequency
-umbrella term that covers heavy menses bleeding & intermenstrual bleeding
-accounts for 1/3 of visits to gyn & 70% of all gyn consults in perimeno & postmeno years
