Dunn: prolapse, bleeding, menopause Flashcards
prolapse types
bladder/ cystocele
bacpassage/ rectocele
womb/ uterine
baden-walker halfway system
ervic at ischial spines- 0 halfway to hymen- 1 to the hymen - 2 halfway past hymen- 3 maximum descent- 4
prolapse Treatment Options
Nothing Conservative Measures including Kegels, Weight Loss Estrogen Cream Pessary Bladder Sling Colposacropexy Colpocleisis
Stress Incontinence
occurs with sneeze, cough, laugh, jog, or do other things that put pressure on your bladder. It is the most common type of bladder control problem in women.
Overactive Bladder
OAB defined based on symptoms
Urgency, with or without urge incontinence, usually with frequency and nocturia
In the absence of pathologic or metabolic conditions that might explain these symptoms
Urge Incontinence
happens when you have a strong need to urinate but can’t reach the toilet in time.
Mixed Incontinence
This is a combination of
Stress incontinence and urge incontinence
DIAPPERS
Delirium - addresses by toileting
Infection – urinary exacerbates incontinence and causes frequency and urgency
Atrophic urethritis and vaginitis – contribute to irritative symptoms
Pharmaceuticals – anticholinergics = detrusor underactivity-may cause retention; cholinergics = detrusor overactivity – may cause frequency;α-agonist=outlet overactivity - may cause retention;α-blockers = outlet underactivity – may cause stress incontinence
Psychological disorders – toileting
Excessive urine production – or physiologic or pharmacologic nocturia
Restricted mobility – toileting
Stool impaction - retention
Urodynamic Studies
Cystometry
- A study of bladder filling: the bladder is filled with fluid and pressures are measured
Uroflowmetry
- Measures of flow rate
Pressure - Flow
- Simultaneous measurement of bladder pressure during contraction with flow to assess degree of obstruction
Electromyographic Studies
- Stimulus evoked responses measure contractions and reflexes: most useful in conjunction with cystometry
dx of overactive bladder
most cases of overactive bladder can be dxed based on:
- pt history, symptom assessment
- physical exam
- urinalysis
initiation of noninvasive treatment does not require an extensive further workup
(rule out DIAPPERS)
OAB–> disabling conditions
increased risk of hospitalization, admission to nursing homes, depression
UTIs and skin irritation
increased risk of falls and fractures (morbidity and mortality)
barriers to tx of OAB
Pt misconceptions and fears (normal aging, not severe or frequent enough tot treat, too embarrassing to discuss, tx will not help)
physician concerns (no validated screening tools, nearly 2/3 are symptomatic for 2 years before seeking tx, 30% of pts who seek tx receive no assessment, nearly 80% not examined)
nocturia
waking 1 or more times to void at night
PALM-COEIN classification for uterine bleeding in nongravid reproductive-age women
Polyp
Adenomyosis
Leiomyoma
Malignancy and hyperplasia
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
algorithm for uterine bleeding
- rule out non-uterine source
- rule out pregnancy
- See how much bleeding it is and whether regular or not
Endometrial Polyp
Hyperplastic overgrowths of endometrial glands and stroma that project from the surface of the endometrium
Common cause of perimenopausal and early postmenopausal uterine bleeding
Generally benign, but malignancy highest in postmenopausal women
Growth of polyps can be stimulated by estrogen therapy or tamoxifen
Uterine Leiomyoma
Most common type of benign tumor in females
- Leiomyosarcoma is malignant variant
Symptoms
- Asymptomatic
- — Abnormal/painful menses
- — Abdominal pain
Subtypes based on location
- Pedunculated
- Subserosal
- Submucosal
- Intramural
Fibroids
Most common benign neoplasia of female genitals
Smooth muscle and connective tissue growth
E/P sensitive (will stop growing during pregnancy and menopause
Rarely (1.5%) become leiomyosarcoma
Complications: torsions and infertility
Adenomyosis
Triad=noncyclical pain, menorrhagia, enlarged uterus w/o adnexal tenderness
Endometrial tissue growth within myometrium
Tx: NSAIDs, OCPs, Progestins, ablation, hysterectomy
Fibroids (Uterine Leiomyomas) - risk factors, etc.
covering
Tend to increase over time as they are stimulated by estrogen
Most common noncancerous tumors of women of childbearing age
1/5 women greater than 30yo will have fibroids
Leading cause of hyterectomy in the US
Present usually with abnormal uterine bleeding or pelvic pain/pressure
Risk Factors
- Race: 2-3x higher in African Americans than Caucasians and tend to present earlier
- Menstrual history: early menarche (,10yo)
- Obesity
- Diet, alcohol: red meats, beer
- HTN
Uterine Fibroids (Leiomyomas) classification and treatment
Classified by position in the uterine wall
- Intramural
- Within uterine cavity: submucosal, pedunculated submucosal, pedunculated vaginal
- Growing outward from the uterus-can be
- – Cervical
- – Subserous
- – Intraligamentous
- – Pedunculated subserous (abdominal)
Treatment Expectant management in those who are asymptomatic or decline medical or surgical treatment
- Symptoms treatment to regulate bleeding (i.e. OCPs)
- GnRH agonist but may return to pretreatment state once therapy is discontinued
- Surgery: Myomectomy, endometrial ablation, Uterine artery embolization, hysterectomy
Uterine Leiomyoma-myxoid degeneration
Larger leiomyomas outgrow blood supply and undergo degeneration
Types of degeneration
- Hyaline
- Cystic
- Red carneous
- Myxoid
Postmenopausal Bleeding
General Considerations
- Uterine bleeding in menopausal women
- Bleeding may be a single episode of spotting or profuse bleeding for days or months
- Usually painless
- – Pain present if cervix is stenotic, if bleeding is severe and rapid, or if infection, torsion, or extrusion of tumor is present
Incidence:
4-11% of postmenopausal women
Etiology of postmenopausal bleeding
Atrophic endometrium-59% Endometrial polyps-12% Endometrial cancer-10% Endometrial hyperplasia-9.8% Hormonal effects-7% Cervical Cancer-<1% Many who take estrogen therapy develop vaginal bleeding Frequency depends upon the regimen used
Atrophic Endometrium
Hypoestrogen causes atrophy of the endometrium and vagina results in microerosions which is prone to light bleeding or spotting
Classic vaginal findings: pale, dry vaginal epithelium that is smooth and shiny with loss of most rugation
Endometrial Hyperplasia
Proliferation of endometrial glands resulting in greater gland-to-stroma ratio than observed in normal endometrium
Postmenopausal women should be estrogen deficient, so endometrial hyperplasia is abnormal and requires an explanation
Endogenous estrogen production from ovarian or adrenal tumors or exogenous estrogen therapy are possible causes
Obese women have high levels of endogenous estrogen due to the conversion of androgens to estradiol, which occur in peripheral adipose tissue
Classification
- Simple or complex hyperplasia without atypia
- Simple or complex hyperplasia with atypia
Cancer
Approx 5-10% of PMB is endometrial cancer
Incidence increases with age
Adenocarcinoma of the endometrium is the most common genital cancer in women over 45 years of age
Management of post-menopausal bleeding
Exclusion of cancer is the main objective; therefore, treatment is usually unnecessary once cancer) or premalignant histology) has been excluded
Atrophy
- Vaginal estrogen therapy
Endometrial polyp
- Polypectomy
Endometrial hyperplasia
- Cyclic progestin therapy
Endometrial hyperplasia with atypia
- Hysterectomy
Carcinoma of endometrium
- Hysterectomy with BSO and LND for staging
terms related to the timing of menopause
Perimenopause – time leading up to menopause -0 the time when ovarian function and hormone production are declining but have not yet stopped
Menopause: a permanent cessation of the menstrual cycle
Greek “meno” (month) and “pausis” (a pause)
Defined as not having a period for 12 months
Post menopause: time in woman’s life after last period
Premature menopause: menopause occurring before age 40
Menopause-Related Changes
Vasomotor symptoms- hot flshes
Sleep quality
Mood changes
Urogenital symptoms
Sexual well-being
Skin changes
Meno-myths
Menopause signifies old age Women go crazy at menopause A woman’s sex life is over at menopause Menopause always causes weight gain Menopause is a medical condition that always needs to be treated
conditions resulting from estrogen deficiency
Well Established: Vasomotor Symptoms Urogenital Disorders CHD Risk Factor (Lipids) Skin Changes
Association:
Cardiovascular Disease
Bone Loss/Osteoporosis
consequences of decreased progesterone
Irregular periods Premenstrual syndrome (PMS)
consequences of decreased androgens
Decrease in mood Diminished energy Impaired sexuality Muscle weakness Osteopenia
Risks and benefits of ht
It is known with good certainty that
HT does not increase CHD risk in women who initiate therapy close to the onset of menopause( within-5 years of last menses)
HT does not prevent and may increase the risk of CHD in women who initiate therapy years after menopause
VTE is an infrequent but well established risk of HT
Risk increases approximately 2-fold with HT use
Greatest risk occurs in the first year of use
Absolute risk remains low in HT users due to the low baseline incidence of VTE in the general, non-hospitalized population
Diseases Associated with Menopause
Coronary Heart Disease
Osteoporosis
Breast Cancer (?)
Colon Cancer (?)
Dementia (?)
New Studies: CAD
Age at initiation of HT determines cardiovascular risk is confirmed
Initially thought to increase risk
However, 18.3% of never-users vs 6.9% of HT users died during follow-up
Starting early equals the most benefit.
JAMA 2007: Women who initiated hormone therapy closer to menopause tended to have reduced CHD risk compared with the increase in CHD risk among women starting HRT more distant from menopause.
Hormone therapy for dementia
Critical window!
Estrogen protects against dementia when taken early in peri-menopause or early in menopause.
In contrast to WHI – (mean age of initiation was 63)
Estrogen-Progestin HT and breast cancer
A WHI analysis confirms a small risk of breast cancer mortality with estrogen-progestin HT
E/P hazard risk was 1.26 in WHI
Now, after follow up for 11 years, combination HT users have similar risk vs. nonusers
Tumors more likely node +
Unopposed estrogen and breast cancer
Estrogen only HT has different risk for breast cancer than E/P HT.
Estrogen only HT decreases risk in all age groups, but benefits younger women more.
(Young = 60 years or less and within 10 years of menopause onset)
estrogen and risks of VTA, CVA
E3N student has shown no increased risk of VTE
Risk of CVA similar to non-users
And in fact, decreased
Transdermal estrogen
The authors believe evidence will eventually point to a superior safety profile for transdermal estrogen vs oral
Offer estradiol gel or spray if patch causes irritation (should have same safety profile)
Micronized progesterone appears safer when progesterone is required
Options for Mild Vasomotor Symptoms
For mild vasomotor symptoms Lifestyle changes (limited efficacy) Nonprescription remedies—tested only short term with little efficacy over placebo but no evidence of harm Dietary isoflavones Black cohosh Vitamin E
Options for Moderate-to-Severe Vasomotor Symptoms
Hormone therapy is the only FDA-approved treatment “gold standard” SSRIs and gabapentin early studies show efficacy women studied have fewer hot flashes than those in HT trials Progestogens effective however, large doses required Clonidine (oral or transdermal)
Duration of HT Use
FDA 20031
Recommends shortest duration and lowest dose consistent with treatment goals
ACOG 20042
The lowest effective estrogen dose should be used for the shortest possible time to alleviate symptoms
NAMS 20043
Recommends duration and dose consistent with treatment goals
American College of Obstetricians and Gynecologists on HT
Hormone therapy remains an effective therapy for treating women with vasomotor symptoms and vaginal atrophy. The benefits and risks should be discussed in detail with each patient before initiating therapy and when renewing her annual prescription so that she can make the best decision for her own health.”
Recommendations from the ACOG Task Force on HT
For women who need or prefer an alternative to HT, data support the use of bisphosphonates or SERMs
In women with menopausal symptoms, HT may be appropriate as a first choice of therapy
All women should be advised to have adequate intake of vitamin D and calcium intake of at least 1,000–1,500 mg/d
After discontinuation of HT or bisphosphonates, the effect of HT withdrawal on bone density should be assessed
HCG and normal/ abnormal pregnancy
If normal – HCG should double every 48 hours
If abnormal – HCG can stay the same, decrease,
or increase minimally
Normal pregnancy - what we see
1ST Trimester bleeding(threatened abortion aka threatened miscarriage)
Physical Findings – cervical os closed, cardiac activity
Transvaginal US –
Gestational Sac at
1,500 – 2,000 MIU
Risk associated with1st trimester bleeding
Miscarriage
Abnormal placental implantation
IUGR
Abnormal pregnancy(in uterus)
Missed abortion
Complete abortion
Incomplete abortion
Molar pregnancy
Risk factors for spontaneous abortion
Maternal age Age 20 to 30 years (9 to 17 percent), age 35 years (20 percent), age 40 years (40 percent), and age 45 years (80 percent) Previous spontaneous abortion ? Increasing gravidity Prolonged time to implantation interval Prolonged time to conception Smoking >10 cigarettes per day EtOH Cocaine NSAIDs around time of conception Caffeine Low folate levels Extremes of maternal weight Fever during early pregnancy Unrecognized celiac disease
Fetal Etiologyof Sp. Ab.
Chromosomal abnormalities
50% of all spontaneous abortions
Most commonly due to aneuploidies
- 52% autosomal trisomy; 19% monosomal X; 22$ polyploidies
- Trisomy 16 is most common, almost always lethal
Congenital abnormalities
Trauma
- Consider chronic villus sampling and amniocentesis
Maternal etiology of sp. Ab.
Uterine structural issues
- Ex: uterine septum, sub mucosal leiomyoma, intrauterine adhesions
Acute maternal infections
- Ex: Listeria monocytogenes, Toxoplasma gondii, parvovirus B19, rubella, herpes simplex, cytomegalovirus
Maternal endocrinopathies
- Ex: thyroid dysfunction, Cushing’s syndrome, PCOS
Hypercoagulable states:
- Ex: SLE, antiphospholipiod syndrome
Unexplained
Sx for spontaneous abortion
Vaginal bleeding
Pelvic pain
Absence of fetal movement (rate, as usually before movement is perceived)
Incidental finding on US/hand-held Doppler
Work up forspontaneous abortion
Hand-held Doppler
Pelvic exam
- Source and severity of bleeding
- Size of uterus
Pelvic US
- Potential predictors include: abnormal gestational sac, abnormal yolk sac, slow fetal HR, sub chorionic hematoma
hCG
- Single value is usually not predictive, but may be useful for BL value if dx is initially uncertain
Blood type antibody screen
- Administer anti-D for Rh(D) negative mothers
Serum progesterone
>4ng/mL is associated with a nonviable pregnancy
Dx of spontaneous abortion
Expectant management if dx in question
The criteria for spontaneous abortion on pelvic ultrasound:
- A gestational sac >25mm in mean diameter that does not contain a yolk sac or embryo
- An embryo with a crown rump length (CRL) >7 mm that does not have cardiac activity
— If gestational sac or embryo are too small for these dimensions, repeat in 1-2 weeks
Criteria for the diagnosis of a failed pregnancy based upon lack of development over time:
- After a pelvic ultrasound showed a gestational sac without a yolk sac, absence of an embryo with heartbeat in >2 weeks
- After a pelvic ultrasound showed a gestational sac with a yolk sac, absence of an embryo with a heartbeat in >11 days
Threatened abortion
Diagnostic criteria for spontaneous abortion are not met
Vaginal bleeding has occurred and the cervical OS is closed
First trimester bleeding may be associated with adverse outcomes later in pregnancy
- Prognosis is worse when the bleeding is heavy or extends into the second trimester
Up to 50% will miscarry
Tx: bed rest and expectant management
Inevitable abortion
Symptoms of vaginal bleeding, crampy pelvic pain, and dilated cervix
- Products of conception can often be felt or visualized through the internal cervical os
- No passage of fetal tissue per os
Tx options:
- Medical abortion
- – Usually with Misoprostol (one time dose of 800 mcg per vaginum, or 600 mcg sublingual)
- Surgical abortion
- – D&C or D&E; Doxycycline 100mg Po for two doses 12 hours part on the day of the procedural to decrease risk of postabortal sepsis
- Expectant management:
- – Majority of expulsions occur in the first two weeks after diagnosis
Incomplete abortion
Vaginal bleeding and/or pain are present, the cervix is dilated, and products of conception are found within the cervical canal on examination
After 12 weeks , the membranes often rupture, and the fetus is passed, but significant amounts of placental tissue may be retained, leading to an incomplete abortion
Tx options:
- Medical abortion
- – Usually with Misoprostol (one time dose of 800 mcg per vaginum, or 600 mcg sublingual)
- Surgical abortion
- – D&C or D&E; Doxycycline 100mg Po for two doses 12 hours part on the day of the procedural to decrease risk of postabortal sepsis
- Expectant management:
- – Usually Staph aureus or mixed infections
Completed abortion
Products of conception are entirely out of the uterus and cervix
Cervix is closed and the uterus is small and well contracted
Vaginal bleeding and pain may be mild or may have resolved
More common outcome than incomplete >12 weeks gestation
Tx: examination of passed tissue to confirm products of conception, transvaginal US to visualize empty uterus, follow hCG levels until zero (should halve within 48-72) hours
Missed abortion
Patient with or without symptoms having a closed cervical OS
- Women may notice that symptoms associated with early pregnancy such as nausea, breast tenderness, etc. have abated and they do not “feel pregnant” anymore
Tx options:
- Medical abortion
- – Usually with Misoprostol (one time dose of 800 mcg per vaginum, or 600 mcg sublingual)
- Surgical abortion
- – D&C or D&E; Doxycycline 100mg Po for two doses 12 hours part on the day of the procedural to decrease risk of postabortal sepsis
- Expectant management:
- – Majority of expulsions occur first two weeks after diagnosis
Risk factors for ectopic pregnancy
Previous Ectopic * PID (worst agent is chlamydia) Assisted Reproductive Technology History of peritonitis Smoking Previous Tubal Ligation
Note– IUD does not increase risk
Treatment for Ectopic pregnancy
Medical – Methotrexate –
Folic acid inhibitor
Surgical – Removal of ectopic
Removal of tube
- future fertility is identical
