Menopause, Pelvic organ prolapse, post menopausal bleeding

Question 1

vulvovaginal atrophy

Answer 1

sequela of low estrogen in post menopausal states but can also happen in postpartum state if woman has been getting anti estrogen medications

Question 2

symptoms of vulvovaginal atrophy

Answer 2

loss of pubic hair, resorption and fusion labia minora, vaginal introitis narrowing, mucosa thinning and loss of rugation

Question 3

what happens to cause the malodorous discharge with vulvovaginal atrophy?

Answer 3

cervical mucus changes causes vaginal PH>5 and causes the malodorous discharge

wet mount will be normal epithelial cells

Question 4

treatment of vulvovaginal atrophy

Answer 4

water based lubricants in intercourse

for moderate to severe symptoms, vaginal (topical) estrogen, not systemic estrogen as it increases risk for VTE and breast cancer

topical estrogen have no increased risk for endometrial thickening so don’t need progesterone.

improves symptoms in 2-3 weeks

Question 5

clobetasol is used to treat

Answer 5

vulvar lichen sclerosis which is due to thinning of the skin

Question 6

vulvar lichen sclerosis presentation

Answer 6

dyspareunia due to loss of vulvar architeture (vaginal introitus narrowing) and they also have vulvar puritits and white vulvar plaques

Question 7

approach to post menopausal bleeding

Answer 7

Question 8

what is primary ovarian insufficiency?

Answer 8

it’s primary ovarian failure in women age <40 yrs

Question 9

presentation of primary ovarian insufficiency or failure

Answer 9

absent menses seen after cessation of oral contraceptives, which can mask menstrural irregularities.

Women see hot flashes, flushing, night sweats and seen with mood disorders and relationship issues (dyspareunia) like vasomotor symptoms of menopause

Question 10

what is seen on labs with primary ovarian insufficiency?

Answer 10

see elevated FSH level and low estrogen and postmenopausal range (consistent with ovarian failure)

most cases of this are idiopathic. but can be result of cancer treatment (radiation, chemotherapy, genetic predisposition with Turner’s syndrome, fragile X syndrome, and autoimmune disorders like oophoritis. (Usually has a history of autoimmune hypothyroidism and family conditions)

Question 11

how to manage primary ovarian insufficiency?

Answer 11

look for underlying etiology with bone mineral density, look for osteoporosis since low estrogen.

Can give estrogen/progesterone containing therapy to hep restore bone strength and control vasomotor symptoms.

Question 12

Asherman syndrome

Answer 12

amenorrhea following uterine instrumentation - suction or currettage or from endometrial infection.

Question 13

Functional hypothalamic amenorrhea is from

Answer 13

relative caloric deficiency leading to low GnRH, FSH and estrogen levels.

would see low FSH and GnRH.

Question 14

Pituitary adenomas causing amenorrhea

Answer 14

see high prolactin levels which inhibits GnRH release and leads to low FSH levels and would see pituitary adneoma symptoms of headache, vision changes and bilateral galactorrhea.

Question 15

Pelvic organ prolapse is

Answer 15

descent of female pelvic organs (bladder, uterus, post hysterectomy vaginal cuff, rectum) that causes herniation into the vagina or the uterus.

Can cause stress urinary incontinence.

Question 16

Risk factors for pelvic organ prolapse are:

what is the clinical presentation.

Answer 16

multiparity, increasing age, obesity and prior hysterectomy

pts present with a feeling of a vaginal bulge, pelvic pressure, or urinary retention or bowel constipation or sexual dysfunction

Question 17

Treatment for pelvic organ prolapse?

Answer 17

asymptomatic pts _no treatmen_t

_symptomatic pt_s are treated with conservative therapy - vaginal pessary, pelvic flow muscle exercises

indications for vaginal pessaries are: preference for nonsurgical management, poor surgical candidates, desire to have kids in the future or recurrent prolapse.

Those who fail conservative surgery need surgical management.

Question 18

Treatment of menopause vasomotor symptoms

Answer 18

Vasomotor symptoms- night sweats, chills, shivering, anxiety, palpitations, hot flashes (upper body, face, chest) and flushing.

non bothersome symptoms or mild courses - maintain healthy weight, do environmental control (avoid triggers for symptoms) , no caffeine, no ETOH, spicy food or tobacco.

FDA does not approve herbal supplements for vasomotor symptoms

non hormone vasomotor symptoms pharmacological treatment - SSRI and SNRI - paroxetine and citalopram (only paroxetine has FDA approval)

can use gabapentin and clonidine too

hormone therapy for vasomotor symptoms: ok to use if woman <60 yrs old and taking within 10 years of menopause onset.

Question 19

using hormone therapy for vasomotor symptoms of menopause is associated with these adverse effects:

Answer 19

Adverse effects of hormone therapy for vasomotor symptoms are: increased risk for stroke, MI and uterine/endometrial cancer. relatively contraindicated in smokers.

contraindications to hormone therapy: history of VTE, clotting disorder, MI, CVA, TIA, estrogen sensitive cancer, liver disease (estrogen is metabolized by liver so if liver is not working will increase estrogen)

Question 20

to see if patient qualifies for hormone therapy for vasomotor symptoms in menopause need to see if they are:

Answer 20

*must be less than 60 yrs

• start hormone therapy WITHIN 10 years of onset of menopause
• no contraindications: cannot use if VTE, estrogen positive cancer, MI, cirrhosis, post menopausal bleeding, smoker (relatively contraindicated)

Based on CAD/MI risk and risk for breast cancer

If ASCVD score >10% no hormone therapy

breast cancer risk - use BCAT and if >5% risk for breast cancer = no hormone therapy

Question 21

if patient has uterus and is menopausal and wants to start hormone therapy what kind of medication do they get?

What kind of medication do they get if they don’t have a uterus?

Answer 21

if has uterus - needs estrogen and progesterone

no urterus - estrogen therapy

6 months of unopposed estrogen is long enough to cause endometrial hyperplasia

expect vasomotor symptoms to improve within weeks to 3 months and if not improved by 6 months need to switch preparations.

Question 22

Adverse effects of systemic hormone therapy for menopausal vasomotor symptoms are:

Answer 22

increased risk for breast cancer

seen after 3-5 years of estrogen only therapy, seen after 7 yrs of combo therapy

increased risk for cardiovascular dx

worse with pts who have ASCVD>10%

increased risk for VTE

• if go into a hospital stop hormone therapy.

increased risk for stroke

• highest risk for oral vs transdermal vs low dose transdermal

Question 23

when to stop hormone therapy?

Answer 23

don’t start systemic hormone therapy if pt >65 years

try to taper after 3-5 years

with severe symptoms try to gradually taper them - transdermal and systemic

if symptoms return can lower taper

Question 24

post menopausal bleeding in women who are not on OCP should be (or on unopposed estrogen)

Answer 24

evaluated to rule out malignancy

hard to rule out if bleeding is from cervix or endometrial lining so will need to have both investigated with a pap smear and an endometrial biopsy.

don’t pick transvaginal U/S to look at endometrial lining thickness because we know that there is bleeding and what if u/s shows that the lining is thin? still needs to be investigated.

Question 25

women who start hormone replacement therapy for menopausal vasomotor symptoms may have:

Answer 25

expect some bleeding after starting estrogen but this should diminish

If vaginal bleeding continues then needs to be investigated.

No OCP or on estrogen only hormone replacement - go to endometrial biopsy

if on cyclic progesterone and has post menopausal bleeding, transvaginal _U/S is acceptable screening test f_or endometrial hyperplasia and cancer.

Question 26

female sexual arousal disorder

Answer 26

women with impairment in reaching or continuing appropriate lubrication and/or clitoreal swelling despite appropriate sexual stimualtion with marked distress as a result of impairment

say that while patients desire to engage in sexual activity there may not be an adequate arousal response.

patient does not feel any excitement or adequate physical changes despite appropriate sexual stimulation.

may be generalized or situational and or may be psychologic and/or associated with a medical condition.

does not result of a mood disorder.

Question 27

female sexual arousal disorder

Answer 27

not able to get clitoral swelling despite appropriate sexual stimulation with marked distress as a result of impairment.

not enough adequate response despite desire.

disorder may be generalized or situational and may be pyschological and or associated with a medical condition

tx with lubricant and sexual health counseling are potential appropriate interventions.

Question 28

female orgasmic disorder is

Answer 28

defined as consistent delay or lack of organsm despite appropriate sexual excitement with respect to age nd sexual circumstances (sexual experience and adequate stimulation)

Question 29

hypoactive sexual desire disorder

Answer 29

result of decreased or absent sexual desires as related to appropriate age and life circumstances.

>6 months of hypoactive sexual desire or arousal dysfunction

not the same thing as sexual aversion disorder due to individuals not necessarily being opposed or resistant to idea of sexual activity but instead find that their interest have overall declined in sexual desires.

make sure no primary mood concern underlying the cause of decreased sexual desires.

Question 30

sexual aversion disorder

Answer 30

diagnosed in patient that have significant resistance or repulsions to the idea of sexual activity or even sexual contact.

Question 31

genitopelvic pain/penetration disorder

Answer 31

persistent or recurrent difficulty in vaginal penetration during intercourse

marked vulvoginal or pelvic pain during penetration and fear of pain or anxiety about pain in anticipation of or during penetration and tightening or tensing of pelvic floor muscles during attempted penetration. need to be present for at least 6 months.