Menopause & pelvic organ prolapse Flashcards
what s climacteric?
Phase in a woman’s reproductive life when a gradual decline in ovarian function results in decreased sex steroid production, and the associated sequelae
when does menopause typically occur?
btwn the ages of 50-55, w/ the avg age of 51.5
contributing factors to age of onset of menopause?
Genetics
Smoking
Hysterectomy
when do the ovaries fail?
When all oocytes have either been ovulated or become atretic
lower levels of hormones often result in…
physical, physiological, and sexual changes
what is perimenopause?
Signs of impending ovarian failure: changes in menstrual cycles, mood and emotional changes, hot flashes or flushes and night sweats, breast changes
what are some hormonal changes seen in menopause?
decr. in estrogen, androgens, progesterone
increased levels of LH and FSH
clinical manifestations of menopause?
gen sxs: hot flushes, insomnia, irritability, mood disturbances, loss of libido, mild depression, skin changes
physical sxs: urogenital atrophy, urinary stress incontinence, skin collagen loss
dz: osteoporosis, CV dz, dementia
Hot flashes?
most women experience but frequency varies
assoc. w/ dizziness, palpitations, sweating, or night time wakening
what are some urogenital sxs seen in menopause?
Vaginal atrophy
Vaginal canal shrinks in diameter
Elastic capacity of the bladder is decreased
dx criteria for menopause?
12 months of amenorrhea in a woman >45yo in the absence of other biological or physiological causes
longitudinal assessment: menstrual cycle hx and menopausal sxs (hot flashes, mood change, sleep disturbance)
management of menopause?
tx targeted at sxs and prevention of complications
atrophic changes, vaginal dryness: non-hormonal vaginal moisturizers & lubricants, also vaginal estrogen therapy
what is ospemifene (ospena) used for?
SERM for mod-severe dyspareunia caused by vulvovaginal atrophy in menopause
no clinically signf. estrogennic effect on endometrium or breast
vaginal prasterone used for?
menopause
DHEA
Aromatization of androstenedione and testosterone locally to estrone and estradiol
tx for pt’s w/systemic sxs in menopause?
Menopause Hormone Therapy (MHT): unopposed estrogen therapy (ET) or combined estrogen-progestin therapy (EPT)
gold standard for relief of vasomotor sxs in menopause
estrogen therapy
tx for menopause: women who still have a uterus should NOT use…
unopposed estrogen
contraindications for menopause hormone therapy?
hx breast cancer, CHD, prior VTE or stroke, active liver disease, unexplained vaginal bleeding, high-risk endometrial cancer, TIA
how to rx menopause hormone therapy?
Prescribe the lowest effective dose for the shortest period of time
estrogen side effects?
breast tenderness
progestin side effects?
bloating, mood sxs
examples of MHT?
Prempro, Prefest, Climara Pro (estrogen/progestin)
Estratest (estrogen/testosterone)
Premarin, Femtrace, Climara (estrogen only)
Duavee (bazedoxifene/estrogen)
why not use HRT long-term
increased risks of CHD, stroke, VTE, and breast cancer
when to use HRT for tx of menopause?
tx symptomatic women only
benefits outweigh risks for women under 60y/o
benefits outweigh risks if < 10 yrs from menopause
use MHT for short courses
(<5yrs)
do NOT use for prevention of chronic dz (osteoporosis or CHD)
alternative non-hormonal tx’s for vasomotor sxs in menopause?
Venlafaxine (Effexor), Paroxetine (Paxil), Gabapentin (Neurontin), Acupuncture
soy and isoflavones (short term 2 yrs)
st. john’s wort - for mild to mod depression (2yrs) and hot flashes (8wks)
black cohosh (vasomotor for 6mo’s)
bio-identical hormones, plant hormones
pelvic organ prolapse includes…
Anterior compartment prolapse Posterior compartment prolapse Enterocele Apical compartment prolapse Procidentia
what is a cystocele
The downward displacement of the bladder into the vagina usu. assoc. w/childbirth (large baby, multiple, prolonged labor)
commonly assoc. w/urethrocele, sagging of urthera –> cystourethrocele
clinical presentation of cystocele
depends on size
sxs: pelvic pressure, LBP, sensation of “sitting on something”, dyspareunia, urinary incontinence, general dificulty w/urination
PE for cystocele?
Lithotomy position
Thin-walled, smooth bulging mass may be visible in the vaginal vault (ask the patient to cough or bear down)
diagnostic studies for cystocele
usu. clinical dx!!
IVP and/or ultrasound may be of some value (urinary structures)
MRI shows promise as a helpful tool to eval the pelvic floor and the muscles which provide pelvic support
medical management of cystocele
Exercises (i.e. Kegel)
Pessary use
Vaginal weights
No data exists to support systemic or topical estrogen as a therapy for the tx of pelvic organ prolapse
surgical management for cystocele:
Rarely indicated for cystocele alone
surg of choice = anterior colporrhaphy
good prognosis
pt education: wt. loss future pregnancy, bowel health, occupational concerns
what is a rectocele?
Rectovaginal herniation between the rectum and the vagina
clinical presentation for rectocele?
Depends on the size of the rectocele
Pt’s may complain of rectal fullness, straining at stool, a vaginal “bulging” and/or low back pain
PE for rectocele?
Lithotomy position
Rectovaginal examination may facilitate visualization of the rectocele
A soft mass bulging into the vaginal canal may be visualized
Eval the pt for a rectovaginal fistula
diagnostic studies for rectocele
Dynamic cystoproctography will help distinguish between an enterocele, rectocele and a sigmoidocele
+/- MRI
medical management for rectocele
Used for the patient who desires more children, and for the asymptomatic pt
Stool softeners, Kegel exercises, pessary
surgical management for rectocele
Rarely required for the rectocele alone
Traditional colpoperineorraphy: sutures placed in levator ani muscles
what is vaginal prolapse?
Downward displacement of the vaginal apex due to loss of muscle and ligamental support
Typically follows a hysterectomy
clinical presentation for vaginal prolapse?
Pelvic pressure, a sensation of bearing down, dyspareunia, and/or low back pain
Patients may have concomitant cystocel
dx for vaginal prolapse
clinical!
managment for vaginal prolapse
surg. intervention
if pt no longer sexually active –> colpectomy and colpocleisis
if pt desires sexual activity –> vaginal suspension
