Menopause and older age Flashcards
Menopause is a retrospective diagnosis, made after when a woman has no periods for __ months
12
Average age of menopause is __ years old
51
Post-menopause describes the period from ________ months after the final menstrual period onwards.
12 months+
Perimenopause occurs in women older than __ years
45 years
Premature menopause is before the age of ___ years. It is the result of _______________________________.
40 years
Premature ovarian insufficiency (not enough eggs left in ovaries)
During menopause, the following sex hormones change how?
Oestrogen
Progesterone
LH
FSH
Oestrogen - low
Progesterone - low
LH - high
FSH - high
*LH, FSH high due to absence of negative feedback from oestrogen
Why is LH and FSH high with menopause?
Lower oestrogen, therefore no negative feedback on Hypothalamus and Pitutary gland. LH and FSH thus increase.
Inside the follicle, oestrogen is secreted by which cells of the follicle?
Granulosa cells
Without oestrogen, what happens to:
Ovulation
Menstrual cycles
Menstruation
Anovulation
Irregular menstrual cycles
Amenorrhoea
*Also lower levels of oestrogen cause perimenopausal symptoms
Oestrogen can lead to perimenopausal symptoms.
List 5.
Hot flushes Emotional lability / low mood PMS Irregular periods Joint pain Heavier / lighter periods Vaginal dryness / atrophy Reduced libido
A lack of oestrogen with menopause can lead to increased risks of which conditions?
List all 4.
Cardiovascular disease/stroke
Osteoporosis
Pelvic organ prolapse
Urinary incontinence
How is a diagnosing of perimenopause and menopause made in a normal woman?
Woman aged 45+ years and shows typical symptoms.
No investigations needed.
How is diagnosis of menopause made in the following groups:
Women aged under 40 years with suspected premature menopause
Women aged 40-45 years with menopausal symptoms or a change in the menstrual cycle
FSH blood test (?high)
Fertility gradually declines after __ years of age
40
Women need to use effective contraception for:
___ years after last menstrual period in women under 50
___ years after last menstrual period in women over 50
2 years if under 50
1 year if over 50
Do hormonal contraceptives affect menopause - when it occurs, how long it lasts?
No
But it can suppress and mask the symptoms of menopause
Therefore, can make it difficult to diagnose menopause with women on hormone contraceptives.
What are good contraceptive options for women approaching menopause?
Barrier methods Mirena/copper coil Progesterone only pill Progesterone implant Progesterone depot injection (<45 years) Sterilisation
COCP (if advantages outweigh risks) if 40-50 years. - certain ones have less VTE risk such as norethisterone and levonorgesterel.
What are 2 key side effects of the progesterone depot injection (e.g. Depo-Provera)?
Weight gain
Reduced BMD (osteoporosis)
- These S/E do not occur with any other forms of contraception.
- Depot thus is unsuitable for women over 45 years old as they have less protective oestrogen.
What are conservative treatment options for perimenopausal symptoms?
No treatment
CBT
Vaginal moisturisers (Sylk, Replens, YES)
What are pharmacological treatment options for perimenopausal symptoms?
HRT
Tibolone (hormone that acts as continuous combined HRT. Only to be used 12+ months after amenorrhoea)
Clonidine (agonists of alpha-adrenergic and imidazoline receptors)
SSRIs (fluoxetine, citalopram)
Testosterone gel/cream (treat reduced libido)
Vaginal oestrogen cream/tablets (help with vaginal dryness and atrophy. Can be used with systemic HRT alongside)
Pelvic organ prolapse refers to the descent of pelvic organs into the _______.
Vagina
Prolapse is the result of weakness and lengthening of the _______ and _______ surrounding the _______, _______ and ________.
ligaments
muscles
uterus
rectum
bladder
Uterine prolapse is when the uterus itself descends into the _______.
Vagina
Vault prolapse occurs in which women?
What happens during it?
Women who have had hysterectomy (no uterus)
Top of the vagina (the vault), descends into the vagina.
What is a rectocele and what is it caused by?
Defect in posterior vaginal wall
Allows rectum to prolapse forwards into the vagina
Rectocele usually presents with what?
Constipation
Faecal loading (in part of rectum that has prolapsed into the vagina)
Urinary retention (due to compression on urethra)
Palpable lump in vagina (part of rectum that has fallen into it)
How can women with rectoceles self-manage this condition and open their bowels?
Women can use their fingers in their vagina to press the rectal lump backwards.
This corrects the rectum back into its normal anatomical position, and allows them to open their bowels`
What is a cystocele and what is it caused by?
Defect in anterior vaginal wall
Allows bladder to prolapse backwards into the vagina
- prolapse of urethra = urethrocele
- prolapse of both urethra and bladder = cystourethrocele
What are risk factors for pelvic organ prolapse?
Weak, stretched muscles and ligaments. Caused by:
Multiple vaginal deliveries Instrumental, prolonged or traumatic delivery Advanced age/postmenopausal Obesity Chronic resp disease causing coughing Chronic constipation causing straining
What is the typical presentation for someone with pelvic organ prolapse?
Feeling of “something coming down” in the vagina
Dragging/heavy sensation in the pelvis
Urinary symptoms (incontinence, urgency, frequency, weak stream and retention)
Bowel symptoms (constipation, incontinence, urgency)
Sexual dysfunction (pain, altered sensation, reduced enjoyment)
Lump or mass in vagina
Prolapse worse on straining or bearing down
When examining for pelvic organ prolapse, what 2 positions can the woman be placed in?
Dorsal position
Left lateral position
What instrument is key to the vaginal examination in a woman with pelvic organ prolapse?
Sim’s speculum
*U-shaped, single-bladed speculum. Used to support the anterior/posterior vaginal walls while other vaginal walls are examined.
What instructions are important to be given to a woman with suspected pelvic organ prolapse during their vaginal examination?
Cough or “bear down” - allows assessment of full descent of the prolapse
Uterine prolapse severity can be assessed with what score?
POP-Q system (pelvic organ prolapse quantification)
Grade 0: Normal Grade 1: The lowest part is more than 1cm above the introitus Grade 2: The lowest part is within 1cm of the introitus (above or below) Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as a?
Uterine procidentia
What are conservative management options for pelvic organ prolapse?
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes (stress, reduce caffeine, conti pads)
Treat related symptoms (stress incontinence - anticholinergics)
Vaginal oestrogen cream
NB: conservative management used in women with mild symptoms and able to cope or do not tolerate pessaries or are not suitable for surgery.
What is the main medical treatment for pelvic organ prolapse?
Vaginal pessary
*Inserted into the vagina to provide extra support to the pelvic organs.
What is the potential side-effect of using vaginal pessaries?
How can this be treated?
Vaginal irritation/erosion
need to be removed/cleaned or changed periodically
can also use oestrogen cream to help protect vaginal walls from irritation
What are 2 surgical options for treating a pelvic organ prolapse?
Mesh repair (now against NICE guidelines) Hysterectomy
What are surgical complications that can arise from fixing pelvic organ prolapse?
Pain/bleeding/infection/DVT/risk of anaesthetic
Damage to bladder/bowel
Recurrence of the prolapse
Altered experience of sex
What are complications of mesh repair in pelvic organ prolapse?
Chronic pain Altered sensation Dyspareunia (for woman or partner) Abnormal bleeding Urinary or bowel sym,ptoms
*NICE now recommend that mesh procedures should be avoided entirely!
What are the different types of incontinence? (4)
Urge incontinence
Stress incontinence
Mixed (stress+urge) incontinence
Overflow incontinence
Urge incontinence is caused by overactivity of the _________ of the bladder?
Detrusor muscle
Urge incontinence is also known as ________________.
Overactive bladder
Typical presentation:
Urge to pass urine
Rushing to bathroom/caught short
What type of incontinence is this?
Urge incontinence
How can urge incontinence impact on women?
Concious about always having access to a toilet
Avoid activities or places where there is no easy access to toilet
Impact on QoL - stop them doing work or leisure activities accordingly
Stress incontinence is due to the weakness of the ___________ and ___________.
Allows urine to leak at times of ______________ on the bladder
Pelvic floor
Sphincter muscles
Increased bladder
Urinary leakage when laughing, coughing or surprised.
What type of incontinence is this?
Stress incontinence
What are the 3 canals through the centre of the female pelvic floor?
Urethral canal
Vaginal canal
Rectal canal
Mixed incontinence refers to the combination of ________ incontinence and ________ incontinence.
Urge incontinence
Stress incontinence
Overflow incontinence occurs when there is __________________ due to obstruction to outflow of urine.
Chronic urinary retention
Presentation is overflow of urine and incontinence occurs WITHOUT urge to pass urine.
What type of continence is this?
Overflow incontinence
Overflow incontinence can occur with what class of medications?
Anticholinergic medications
What conditions can result in overflow incontinence?
Hints: gynae and neuro
Gynae - fibroids, pelvic tumours
Neuro - MS, diabetic neuropathy, spinal cord injuries
How does the prevalence of overflow incontinence compare in men and women?
Men > women
How should women with suspected overflow incontinence be investigated?
Urodynamic testing
then specialist management
What are risk factors for urinary incontinence?
List at least 4.
Increased age Postmenopausal status Increased BMI Previous pregnancies and vaginal deliveries Pelvic organ prolapse Pelvic floor surgery Neuro conditions, such as MS Cognitive impairments and dementia
What is the best way to differentiate between the different types of incontinence?
Medical history
E.g.
Urinary leakage with coughing/sneezing = stress incontinence
Sudden urge to pass urine with loss of control on the way to the toilet = urge incontinence
What are modifiable risk factors that can contribute to incontinence symptoms?
Caffeine consumption
Alcohol consumption
Medications
BMI
How can the severity of incontinence be assessed in a medical history?
Ask about:
Frequency of urination
Frequence of incontinence
Night-time urination
Use of pads and changes of clothing
Examination for incontinence should assess the ______ tone
Pelvic
Pelvic organ prolapse
Atrophic vaginitis
Urethral diverticulum
Pelvic masses
Are all possible findings on examination for what condition?
Incontinence
During an examination for incontinence, how would you differentiate stress incontinence?
Ask patient to cough and watch for leakage from the urethra
How are the strength of pelvic muscle contractions assessed during an examination for incontinence?
Bimanual examination (asking woman to squeeze against the examining fingers)
*Graded using the modified Oxford grading system:
0: No contraction 1: Faint contraction 2: Weak contraction 3: Moderate contraction with some resistance 4: Good contraction with resistance 5: Strong contraction, a firm squeeze and drawing inwards
What investigations can be carried out to diagnose incontinence?
Bladder diary
Urine dipstick testing (?infection, haematuria, other pathology)
Post-void residual bladder volume (bladder scan to assess for incomplete emptying)
Urodynamic testing (?urge incontinence if not responding to 1st line medical treatments, difficulties urinating, urinary retention, previous surgery or unclear diagnosis) Not always required where diagnosis is possible based on history and examination.
During urodynamic testing, cystometry measures what?
Detrusor muscle contration and pressure
During urodynamic testing, uroflowmetry measures what?
Urine flow rate
During urodynamic testing, leak point pressure measures what?
Point at which bladder pressure results in leakage of urine
- patient asked to cough, move or jump when bladder is filled to various capacities
- assesses for stress incontinence
During urodynamic testing, video urodynamic testing can be done. What does this involve?
Fill bladder with contrast and take X-rays as bladder empties.
Only performed when necessary and not routine part of urodynamic testing
What are conservative management options for stress incontinence? (4)
Avoid caffeine, alcohol, diuretics, overfilling bladder
Avoid excess/restricted fluid intake
Weight loss (if appropriate0
Supervised Kegel exercises (3+ months before considering surgery) -> aim for 8 contractions 3x daily. Aim to strengthen pelvic floor muscles.
What is the main drug used in the 2nd line managing stress incontinence?
(i.e. when conservative 1st line measures have not worked)
Duloxetine (SNRI antidepressant)
*used second line when surgery is less preferred.
What are the surgical options for treating stress incontinence?
List 1. (out of 5)
Tension-free vaginal tape (TVT)
Autologous sling procedures
Colposuspension
Intramural urethral bulking
if the above have failed, artificial urinary sphincter (especially in stress incontinence caused by neuro disorder)
What are conservative management options for urge incontinence? (4)
Bladder retraining
What are 2 pharmacological options that can be used for urge incontinence?
Anticholinergic medications (e.g. oxybutynin, tolterodine, solifenacin) - relaxes detrusor muscle
Mirabegron (alternative to anticholinergic - beta-3-agonist - relaxes detrusor muscle
What are side-effects of the anticholinergic medications (e.g. oxybutinin) that can be used to treat urge incontinence?
Anti-cholinergic side effects:
Dry mouth Dry eyes Urinary retention Constipation Postural hypotension Cognitive decline Memory problems Worsening of dementia
Why is mirabegron sometimes used to manage urge incontinence, instead of anticholinergics like oxybutinin?
Less anticholinergic burden (less of the associated side effects of anticholinergics)
Works as beta-3-agonist
*contraindicated in uncontrolled HTN (b-3-agonist stimulates sympathetic nervous system and raises BP –> hypertensive crisis —> risk of TIA/stroke)
What are surgically invasive options for managing urge incontinence?
Botulinum toxin type A injection into bladder wall
Percutaneous sacral nerve stimulation (device implanted that stimulates sacral nerves)
Augmentation cystoplasty (uses bowel tissue to enlarge the bladder)
Urinary diversion (redirect urinary flow to a urostomy placed on the abdomen)
