menopause Flashcards
What is climacteric
Phase characterized by gradual decline in ovarian function, leading to decreases sex steroid production
What are the aspects of climacteric
Menopausal transition: cycle length changes, increased FSH, ends with final period
Perimenopause: up to 12 months after FMP
Menopause: 12 months of amenorrhea in 45+y/o, w/o other cause
Post-Menopause: early is first 5 years, last is from 5 years after FMP to death
What factors affect the age of menopause onset
genetics
smoking
hysterectomy
(typical 50-55, mean 51.5)
What makes menopause occur
All oocytes have been ovulated or become atretic, ovaries begin to fail
lower levels of hormones= physical, physiological, and sexual changes
Signs of impending ovarian failure (perimenopause) include
Menstrual cycle changes mood/emotional changes (irritable) hot flashes night sweats breast changes (tender)
Hormone changes in menopause include
Decreased estrogen
Decreased androgens (facial hair growth, decreased breast size)
Decreased progesterone (irregular vaginal bleeding)
Increased LH, FSH
Physical changes that occur with menopause include
Urogenital atrophy (vag canal shrinks in diameter)
Urinary stress incontinence (bladder elasticity decreases)
skin collagen loss
Diseases that occur in conjunction with menopause include
Osteoporosis
CVD
Dementia
Hot flashes may present along with
dizziness, palpitations, sweating, night time wakening
Other Sx of menopause are
Confusion, memory loss mild depression skin changes loss of libido fatigue, insomnia
Differential for menopause diagnosis should include
Hyperthyroid (irregular menses, sweats, mood)
Pregnancy, hyperPRL, thyroid (irregular menses)
meds, Pheo, malignancy (hot flash, night sweats)
How do you manage menopausal atrophic vaginal changes
non-hormonal vaginal moisturizers and lubricants
vaginal estrogen therapy
Ospemifene
Vaginal prasterone
What is Ospemifene
selective estrogen receptor modulator (SERM)
used to Tx mod-severe dyspareunia 2/2 vulvovaginal atrophy
does not affect endometrium or breast
What is vaginal prasterone
DHEA; converts testosterone to estrone and estradiol
How do you manage systemic menopausal symptoms
menopause hormone therapy: unopposed estrogen/ estrogen&progesterone
Take lowest effective dose for shortest period of time possible
no unopposed estrogen if you have a uterus
Contraindications to menopause hormone therapy include
Hx breast cancer CHD Hx DVT/VTE/CVA liver disease unexplained vaginal bleeding high risk endometrial cancer TIA
GOLD standard for relieving vasomotor Sx of menopause
Estrogen therapy
ADE of medical hormone therapy include
Estrogen: breast tenderness
Progesterone: bloating, mood Sx
How do you manage vaginal bleeding
Prempro, Prefest, Climapro (E&P)
Estratest (E&testosterone)
Premarin, Femtrace, Climara (E)
Duavee (bazedoxifen&E)
WHO says not to use MHT long term because
A study on postmenopausal women 50-79 was d/c early 2/2 increased risks of CHD, stroke, VTE, and breast cancer in women taking estrogen alone, and estrogen/progesterone
Why is WHO data not that impressive
It is mostly from women 60+, and most women with Sx of menopause are 40-50
So, the data is based on low quality evidence
Bottom line with the WHO study is
Treat SYMPTOMATIC women only
If <60, only treat no benefit > risk
benefit > risk if <10 years form menopause
Do NOT use MHT to prevent chronic diseases, like osteoporosis
MHT should be use for how long
5 years or less
Alternative non-hormonal treatments for vasomotor Sx include
Venlafaxine Paroxetine Gabapentin Acupuncture Soy & Isoflavones (short term, 2 yrs) St. John's Wort (8 wks) Black Cohosh (6 months) Bioidentical hormonea, plant hormones
St John’s wort can be used to treat
mild-moderate depression, for 2 years
hot flashes, for 8 weeks
What are the types of pelvic organ prolapse
Anterior: bladder Posterior: rectal Apical: apex of vagina Procidentia: all 3 compartments Enterocele: intestines
What is a cystocele
downward displacement of bladder into vagina
associated w/ childbirth (large or multiple babies, prolonged labor), age, obesity, chronic constipation
Associated w/ urethrocele (sagging of urethra)
How does a cystocele present usually
Pelvic pressure low back pain sensation of "sitting on something" worse with valsalva better when supine Dyspareunia, urinary incontinence, difficulty urinating
On PE with a cystocele, you will see
When in the lithotomy position, a thin walled, smooth bulging mass in the vaginal vault
(have patient cough/bear down)
DDx for a cystocele include
urethral or bladder diverticulum
enterocele
How do you diagnose a cystocele
Clinically!
IVP (allows you to assess urinary structure)
US (info about bladder, urethra, etc.
MRI (eval pelvic floor muscles)
How do you manage a cystocele
Exercise (kegels)
pessary
vaginal weights
Surgical intervention of choice for a cystocele is
anterior colporrhaphy +/- bladder sling for stress incontinence
-rarely indicated for cystocele alone!
Educate patient with a cystocele on
weight loss
future pregnancy (cant again)
bowel health
occupational concerns
What is a rectocele
rectovaginal herniation between rectum and vagina
How does a rectocele present
rectal fullness, straining at stool, vaginal “bulging”, low back pain
You should evaluate a patient with suspected rectocele for
Rectovaginal fistula (do PE just as cystocele)
How do you diagnose a rectocele
Clinically!
dynamic cystoproctography helps tell rectocele vs enterocele vs sigmoidocele
-not popular bc you take an XR while peeing/pooping
How do you manage a rectocele
stool softeners
Kegels
Pessary
-Tx if pt wants more kids, and if ASx
What surgery is indicated for a rectocele
Colpoperineorraphy w/ sutures placed in levator ani muscles
-rarely required for rectocele alone
What is vaginal prolapse
downward displacement of the vaginal apex 2/2 loss of muscle and ligament support
common s/p hysterectomy
How does vaginal prolapse present
pelvic pressure, sensation of bearing down, dyspareunia, low back pain
concomitant cystocele
How do you manage vaginal prolapse
Not sexually active: Colpectomy and Colpocleisis
Sexually active: vaginal suspension
Surgery is usually indicated
What are the types of pessaries
Incontinence ring
Donut
Gellhorn
Gehrung
