Menopause & pelvic organ prolapse

Question 1

what s climacteric?

Answer 1

Phase in a woman’s reproductive life when a gradual decline in ovarian function results in decreased sex steroid production, and the associated sequelae

Question 2

when does menopause typically occur?

Answer 2

btwn the ages of 50-55, w/ the avg age of 51.5

Question 3

contributing factors to age of onset of menopause?

Answer 3

Genetics
Smoking
Hysterectomy

Question 4

when do the ovaries fail?

Answer 4

When all oocytes have either been ovulated or become atretic

Question 5

lower levels of hormones often result in…

Answer 5

physical, physiological, and sexual changes

Question 6

what is perimenopause?

Answer 6

Signs of impending ovarian failure: changes in menstrual cycles, mood and emotional changes, hot flashes or flushes and night sweats, breast changes

Question 7

what are some hormonal changes seen in menopause?

Answer 7

decr. in estrogen, androgens, progesterone

increased levels of LH and FSH

Question 8

clinical manifestations of menopause?

Answer 8

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

Question 9

Hot flashes?

Answer 9

most women experience but frequency varies

assoc. w/ dizziness, palpitations, sweating, or night time wakening

Question 10

what are some urogenital sxs seen in menopause?

Answer 10

Vaginal atrophy

Vaginal canal shrinks in diameter

Elastic capacity of the bladder is decreased

Question 11

dx criteria for menopause?

Answer 11

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)

Question 12

management of menopause?

Answer 12

tx targeted at sxs and prevention of complications

atrophic changes, vaginal dryness: non-hormonal vaginal moisturizers & lubricants, also vaginal estrogen therapy

Question 13

what is ospemifene (ospena) used for?

Answer 13

SERM for mod-severe dyspareunia caused by vulvovaginal atrophy in menopause

no clinically signf. estrogennic effect on endometrium or breast

Question 14

vaginal prasterone used for?

Answer 14

menopause

DHEA

Aromatization of androstenedione and testosterone locally to estrone and estradiol

Question 15

tx for pt’s w/systemic sxs in menopause?

Answer 15

Menopause Hormone Therapy (MHT): unopposed estrogen therapy (ET) or combined estrogen-progestin therapy (EPT)

Question 16

gold standard for relief of vasomotor sxs in menopause

Answer 16

estrogen therapy

Question 17

tx for menopause: women who still have a uterus should NOT use…

Answer 17

unopposed estrogen

Question 18

contraindications for menopause hormone therapy?

Answer 18

hx breast cancer, CHD, prior VTE or stroke, active liver disease, unexplained vaginal bleeding, high-risk endometrial cancer, TIA

Question 19

how to rx menopause hormone therapy?

Answer 19

Prescribe the lowest effective dose for the shortest period of time

Question 20

estrogen side effects?

Answer 20

breast tenderness

Question 21

progestin side effects?

Answer 21

bloating, mood sxs

Question 22

examples of MHT?

Answer 22

Prempro, Prefest, Climara Pro (estrogen/progestin)
Estratest (estrogen/testosterone)
Premarin, Femtrace, Climara (estrogen only)
Duavee (bazedoxifene/estrogen)

Question 23

why not use HRT long-term

Answer 23

increased risks of CHD, stroke, VTE, and breast cancer

Question 24

when to use HRT for tx of menopause?

Answer 24

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)

Question 25

alternative non-hormonal tx’s for vasomotor sxs in menopause?

Answer 25

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

Question 26

pelvic organ prolapse includes…

Answer 26

Anterior compartment prolapse
Posterior compartment prolapse
Enterocele
Apical compartment prolapse
Procidentia

Question 27

what is a cystocele

Answer 27

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

Question 28

clinical presentation of cystocele

Answer 28

depends on size

sxs: pelvic pressure, LBP, sensation of “sitting on something”, dyspareunia, urinary incontinence, general dificulty w/urination

Question 29

PE for cystocele?

Answer 29

Lithotomy position

Thin-walled, smooth bulging mass may be visible in the vaginal vault (ask the patient to cough or bear down)

Question 30

diagnostic studies for cystocele

Answer 30

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

Question 31

medical management of cystocele

Answer 31

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

Question 32

surgical management for cystocele:

Answer 32

Rarely indicated for cystocele alone

surg of choice = anterior colporrhaphy

good prognosis

pt education: wt. loss future pregnancy, bowel health, occupational concerns

Question 33

what is a rectocele?

Answer 33

Rectovaginal herniation between the rectum and the vagina

Question 34

clinical presentation for rectocele?

Answer 34

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

Question 35

PE for rectocele?

Answer 35

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

Question 36

diagnostic studies for rectocele

Answer 36

Dynamic cystoproctography will help distinguish between an enterocele, rectocele and a sigmoidocele

+/- MRI

Question 37

medical management for rectocele

Answer 37

Used for the patient who desires more children, and for the asymptomatic pt

Stool softeners, Kegel exercises, pessary

Question 38

surgical management for rectocele

Answer 38

Rarely required for the rectocele alone

Traditional colpoperineorraphy: sutures placed in levator ani muscles

Question 39

what is vaginal prolapse?

Answer 39

Downward displacement of the vaginal apex due to loss of muscle and ligamental support

Typically follows a hysterectomy

Question 40

clinical presentation for vaginal prolapse?

Answer 40

Pelvic pressure, a sensation of bearing down, dyspareunia, and/or low back pain

Patients may have concomitant cystocel

Question 41

dx for vaginal prolapse

Answer 41

clinical!

Question 42

managment for vaginal prolapse

Answer 42

surg. intervention

if pt no longer sexually active –> colpectomy and colpocleisis

if pt desires sexual activity –> vaginal suspension