Menopause & Pelvic Organ Prolapse

Question 1

Climacteric phase

Answer 1

gradual decline in ovarian function resulting in decreased sex steroid production, and associated sequelae

Question 2

What happens during menopausal transition?

Answer 2

1. FSH increases!
2. changes in cycle length

-this stops at the final menstrual period (FMP)

Question 3

Perimenopause

Answer 3

1. FSH increases!
2. change in cycle length

-Goes through to 12 months after final menstrual period

Question 4

Menopause: definition

Answer 4

Officially after 12 months of amenorrhea after FMP in women >45yr

Question 5

Distinguish early versus late post menopause

Answer 5

early: first 5 years of menopause
late: starting 5 years after start of menopause until death

Question 6

What is the name for the staging used for classifying peri and post menopause?

Answer 6

STRAW staging

Question 7

When does menopause typically happen?

Answer 7

50-55

avg is 51.5

Question 8

Describe the hormonal changes of perimenopause (5)

Answer 8

Decrease

1. Estrogen
2. Androgen (facial hair, decreased breast size)
3. Progesterone (irregular vaginal bleeding

Increase

1. LH (hot flashes)
2. FSH

Question 9

Describe the urogenital symptoms of menopause

Answer 9

• vaginal atrophy
• elastic capacity of bladder decreased
• stress incontinence

Question 10

For a patient with vaginal dryness, what is the 1st and 2nd line therapies?

Answer 10

1st line: vaginal lubricants

2nd line: vaginal estrogen

Question 11

3rd line therapy for vaginal dryness/moderate to severe dyspareunia (pt. can’t have estrogen)?

Answer 11

Ospemifene (SERM)

or

Vaginal Prasterone (DHEA)
-converts to estradiol

Question 12

If your patient has a uterus, what should they not be prescribed?

Answer 12

unopposed estrogen

Question 13

Your patient has vasomotor (hot flush) symptoms. What is the gold standard treatment?

Answer 13

estrogen therapy

Question 14

What are the contraindications of estrogen therapy?

Answer 14

• Hx breast cancer
• CHD
• Prior VTE
• Stroke
• Active liver disease
• Unexplained vaginal bleeding
• High risk for endometrial cancer

Question 15

For estrogen therapy what is the guiding principle for use?

Answer 15

use the lowest effective dose for the shortest period of time. (<5 years)

Question 16

Estrogen side effect

Answer 16

breast tenderness

Question 17

Progestin side effects

Answer 17

bloating, mood symptoms

Question 18

What was the goal of Women’s Health Initiative?

Answer 18

to see if hormone replacement would lower cardivascular events

Question 19

What was Women’s Health Initiative stopped early?

Answer 19

increased risk of coronary heart disease, stroke, VTE, and breast cancer :(

(partially because they initiated treatment in 60 year olds, not women starting menopause in 40s-50s

Question 20

Does estrogen alone or estrogen + progesterone increase coronary events?

Answer 20

estrogen + progesterone

Question 21

Does estrogen alone or estrogen + progesterone increase risk of invasive breast cancer?

Answer 21

Estrogen + progesterone

Question 22

What two things does estrogen + progesterone lower risk of?

Answer 22

1. osteoporosis

2. Risk of colon cancer

Question 23

Who should you consider treatment with HRT in menopause?

Answer 23

• If symptomatic
• If under 60
• If <10 years from start of menopause

DO NOT use HRT for treatment of chronic diseases (ex. osteoporosis)

Question 24

Cystocele

Answer 24

• bladder displaced into the vagina

- associated with child birth** (big baby, multiple deliveries, prolonged labor)

Question 25

If the patient presents with pelvic pressure, low back pain, and sensation of "sitting on something" what if the most likely diagnosis?

Answer 25

Cystocele

Question 26

What makes a cystocele better or worse?

Answer 26

Worse: coughing, sneezing, val salva better: lying down

Question 27

When performing a pelvic exam on a pt. with suspected cystocele, what will you have the patient do?

Answer 27

cough or bear down in order to see thin-walled, smooth, bulging mass

Question 28

If the patient has a cystocele, what are the treatments you might offer?

Answer 28

- Kegel exercises - Pessary use - Vaginal weights

Question 29

Although rarely indicated for cystocele alone, what is the surgery for repairing this?

Answer 29

anterior colporrhaphy

Question 30

Cystocele: patient education

Answer 30

- Don't get constipated - Lose weight - Future pregnancy will compound problem

Question 31

Patient presents with rectal fullness, straining at stool, chronic constipation, a vaginal bulging and/or low back pain

Answer 31

Rectocele

Question 32

What diagnostic study can help distinguish between enterocele, rectocele and sigmoidocele?

Answer 32

Dynamic Cystoproctography

Question 33

What is the surgical management for a rectocele?

Answer 33

(rarely done for rectocele alone) -Traditional colpoperineorraphy (sutures in the levator ani muscles)

Question 34

Vaginal prolapse typically follows which proceedure?

Answer 34

hysterectomy

Question 35

For vaginal prolapse there are two different surgical interventions depending on whether or not the patient is still sexually active. What are they?

Answer 35

Sexually active = vaginal suspension Not sexually active = colpectomy and colpocleisis