Menopause & POP Flashcards
perimenopause (menopausal transition)
he preceding time period during the physiologic changes associated with menopause occur
Menopause
permanent cessation of menses for 12 consecutive months
Postmenopause
The period following menopause
age of perimenopause
4 years before final menstrual period (FMP)
manifestations of perimenopause
estrogen fluctuates unpredictably IRREGULAR MENSES vasomotor sx (hot flashes/night sweats) Mood sx (anxiety/depression) vaginal dryness change in lipids and bone loss begin
Labs for perimenopause
FSH >25 suggestive
Median age of menopause
51.5 YO
Abnormal menopause
before 40 YO (primary ovarian insufficiency/premature ovarian failure)
Labs for menopause
FSH >70 (post-meno women)
Sx of postmenopause
vasomotor- untreated, hot flashes stop spontaneously 4-5 years of onset
vaginal dryness
increased risk of osteoporosis, CVD, dementia
Mood sx (anxiety/depression)
Women with worst hot flashes
african american
women w/ fewest vasomotor sx
Asian
Length of hot flash
1-5 minutes
Tx for vasomotor sx
- Lifestyle modification
- Hormone Therapy (Estrogen vs Estrogen/Progestin)
- SSRIs and SSNRIs
- Clonidine
- Gabapentin
- Complementary Botanicals and Natural Products (Phytoestrogens, Herbal Remedies, Vitamins, Accupuncture)
• Not recommended: progestin‐only medications, testosterone, or compounded bioidentical hormones
Most effective therapy for menopause
Systemic hormone therapy (HT)
Cause of hotflashes
narrowing of thermoregulatory zones
Types of HT
estrogen only- women who have undergone hysterectomy
estrogen + progestin: intact uterus
Adverse effect of unopposed estrogen in woman w/ uterus
endometrial hyperplasia
increased risk of endometrial adenocarcinoma
SE of HT
breast tenderness
vaginal bleeding
bloating
h/a
low-dose estrogen has less SE but not as effective – treat w/ lowest effective dose for shortest duration to relieve vasomotor symtpoms (no more than 5 years or beyond age 50)
When to stop HT
5 years after start or beyond age 60
Risks of HT
thromboembolic disease
Breast CA
Combined HT: Breast CA, CHD, stroke, venous thromboembolic events; decreased fx and colon Ca
Estrogen only: only increased risk of thromboembolic (no CVD or breast CA)
Benefit of transdermal estrogen
lower risk of venous thromboembolism compared to oral
Contraindications of HT
hx of: • Breast cancer • Coronary Heart Disease • Previous venous thromboembolic event or stroke • Active liver disease • unexplained vaginal bleeding • high‐risk endometrial cancer • transient ischemic attack
No risk of CVD or breast CA
estrogen only
Role of progestin
prevent endometrial hyperplasia and endometrial CA
may improve vasomotor sx somewhat
Why is progestin not used alone?
Risk of breast CA
Why is T not used?
no benefit for vasomotor sx clitoromegaly hirsuitism acne lipid effects
T good for
improves sexual function
what are bioidentical hormones?
Plant‐derived hormones that are similar to those produced by the body (micronized progesterone and estradiol)
Types of bioidentical hormones
micronized progesterone and estradiol
dosing for bioidentical hormones
salivary hormone level testing to customize dosing – expensive and useless (hormones vary)
Nonhormonal meds for hot flashes
SSRI’s
SNRI’s
Antiepileptic/central-acting
SSRI’s
Low-dose paroxetine
Paroxetine (FDA)
CItalopram
Escitalopram
SNRI’s
Venlaxafine
Desvenlafaxine
Antiepileptics/central-acting
Gabapentin
Pregabalin
Clonidine
Alternative therapies
Phytoestrogens (soy based, red clover)
herbal (black cohosh, ginseng, St. john’s worst, ginkgo biloba)
Vit E
Accupuncture
GU syndrome of menopause sx
vulvovaginal atrophy (dryness, itching, dyspareunia, sexual dysfunction)
Urinary frequency
Recurrent bladder infections
Tx for vulvovaginal atropy
water-soluble moisturizers/lubes
HT
- local estrogen (cream, ring, tablet)
- estrogen agonists and antagonists (SERMs): stimulate or inhibit estrogen receptors (Ospemifene)
Caution w/ local estrogen for atrophy
h/o breast cancer (can still consider it)
Ospemifene
SERM: stimulate estrogen receptors in the vagina; unknown effect elsewhere
Osteoporosis risk factors
(ACCESS) alcohol corticosteroid calcium low estrogen low smoking sedentary lifestyle
Risk factors for osteoporosis
• Advanced age • Cigarette smoking • FH of osteoporosis • Vitamin D deficiency • Female sex • White or Asian ethnicity • Secondary osteoporosis - Endocrinologic disorders - Hormonal factors - Medical disorders (RA) • Long‐term glucocorticoid therapy • Low body weight • Excess alcohol intake
Ethnicity w/ lowest rate of osteoporosis
african american
Preventing osteoporosis
weight-bearing, resistance exercises
walking and aerobics
Vit D
Calcium
Calcium levels recommended
9-18: 1300
19-50: 1000
51-70: 1200
>71: 1200
Vit D level recommended
9-70: 600
>71: 800
Dx of osteoporosis
DXA (T-score and Z-score
T- score used in post-menopausal women
Fragility fx: spine, hip, wrist, humerus, rib and pelvis (fall or standing height or less)
T-score
BMD in sex-matched young normal controls
Z-score
BMD in same age
T-score values
normal: > -1.0
Osteopenia: -1 - -2.5
Osteoporsis: =< 2.5
Screening for osteoporosis
Normal healthy: 65 YO
Postmenopausal w/ risk factors: screen earlier
Risk factors to screen early for osteoporosis
- Medical history of a fragility fracture
- Body weight less than 127 lb
- Medical causes of bone loss (medications or diseases)
- Parental medical history of hip fracture • Current smoker
- Alcoholism
- Rheumatoid arthritis
- FRAX 10‐year risk of major osteoporotic fracture > 9.3%
Tx for osteoporosis types
Lifestyle mod
Pharm
Candidates for osteoporosis therapy
postmenopausal w/ hx of hip/vertebral fx
T-score <= 2.5
High-risk postmenopausal w/ T-score between -1 and -2.6 (10-year risk >= 20% or risk of hip fx >3%)
Pharm tx for osteoporosis
BISPHOSPHONATES (1st line)
SERMs
Forteo (teriparatide (PTH-134))
Calcitonin (maicalcin)
Role of bisphosphonates
reduce bone resorption and turnover
Bisphosphonate drugs
Alednronate
Risedronate
Ibandronate
Zoledronic Acid
SE of bisphosphonates
UGI
Osteonecrosis of jaw
SERM drug for osteoporosis
Raloxifene
Goal of raloxifene
inhibit bone resorption
decrease risk of vertebral fx
reduce risk of breast CA
Used in severe osteoporosis or those that can’t take bisphosphonates, or refractory cases
Teriparatide (PTH-134)
Calcitonin
PTH antagonist
Less preferred
useful in short-term tx of acute pain relief (vertebral fx)
Monitoring for osteoporosis
- Normal BMD (T score 0 to ‐1.5): Repeat in 5‐15 years
- Osteopenia (T‐score of –1.5 to –1.99): Repeat in 5 years
- Osteopenia (T‐score of –2 to –2.49): Repeat in 1 years
- Osteoporosis on treatment: Repeat in 1‐2 years, and 2 years thereafter
Types of POP
Atypical (uterovaginal, vaginal vault (enterocele)
Anterio compartment (cystocele)
Posterior compartment (rectocele)
Procidentia
Sx of POP
only a problem if having sx:
• Bulge/Something falling outside of vagina
• Heaviness
• Pressure
• Discomfort
• Urinary Symptoms (Incontinence vs retention)
• Defecatory Symptoms (with posterior defects)
• Splinting
• Pain and irritation
Risk factors for POP
Parity (vaginal deliveries) Large BW babies Advancing age obesity CT disorders Menopausal status Chronic disease (Constipation, COPD) Iatrogenic (prior prolapse surgery at increased risk) Racial/genetic
Ethnicity w/ lowest risk of POP
African
Ethnicity w/ hight risk of POP
hispanic women
PE for POP
neuro (voluntary mm. control, pelvic floor reflex) GYN exam (valsalva, cough)
Tx for POP
Expectant
Conservative (pessary, Kegels)
Surgery (symptomatic who failed or decline conservative)
Advantages of pessaries
safe
effective
Disadvantages of pessaries
odor
d/c
vaginal ulcers
most remove for coitus
Risk of pessaries
- Erosion into bladder
- Fistula formation
- Ureteral obstruction with urosepsis or uremia
- Small bowel prolapse and incarceration
Surgery type for POP
Apical support (sacrospinous fixation, uterosacral ligament fixation) Sacrocolpopexy
Sacrocolpopexy
Attachement of vagina or cervix to the anterior longitudinal ligament of the sacrum (goal: correct all compartments)
when is POP urgent/emergent?
almost never
urinary retention
obstructive nephropathy
Tx of urinary retention/obstructive nephropathy
indwelling catheter
urogyn consult for pessary or surgery
