Post-menopause

Question 1

Causes of post-menopausal bleeding

Answer 1

Atrophic endometritis and vaginitis
Exogenous oestrogen use
Cervical cancer
Endometrial Cancer
Endometrial or cervical polyps

Question 2

Risk factors for endometrial cancer

Answer 2

Nulliparity
Oestrogen exposure
- Late menopause (>52 years old)
- Early menarche
- Unopposed oestrogen therapy
Obesity
Diabetes mellitus
PCOS
Tamoxifen use
Atypical endometrial hyperplasia
Lynch Syndrome

Question 3

Investigation for post-menopausal bleeding

Answer 3

Mainly directed at excluding either cervical or endometrial cancer.

• Refer to gynaecologist to perform endometrial biopsy. Should ideally be within 6 weeks of referral.
• TVUS to review for Endometrial thickness. Request thickness on form.
  
  • 4, 5, 12mm rule for endometrial thickness
  • 4mm in post, 5mm in peri and 12mm in premenopausal women are acceptable endometrial thicknesses.
    If on tamoxifen - Proceed directly to endometrial biopsy. TVUS not sensitive or specific for neoplasia for women on tamoxifen.

HRT? Bleeding may be expected SE for firsts 6 months.

Question 4

Examination assessment of urinary incontinence in women

Answer 4

Palpate bladder - Palpable after voiding = chronic retention
Genital examination to look for
- Atrophic vaginal mucosa - Can contribute to urge incontinence
- Pelvic organ collapse
- Pelvic mass or tenderness - Bimanual to exclude other pathology that can contribute to incontinence.
- Perform cough test to review for incontinence.
Rectal examination to review for constipation and anal tone.
Neurological screen to review for LMN problems (LL neurological exam as well as review of perineal sensation)
Cardiac - Review for signs of heart failure and volume status - Can cause prominent nocturia.

Question 5

Investigations for urinary incontinence

Answer 5

Bladder diary - Review fluid intake and micturition hourly. Also record episodes of incontinence.
Urine MCS - Exclude UTI
Fasting BSL - Screen for diabetes causing polyruria.

Question 6

Non-pharmacological management for urinary incontinence

Answer 6

Avoid drinking excessive amounts of fluid
Avoid bladder irritants including caffein and alcohol
Bladder training - timed voiding, establish voiding intervals
Pelvic floor exercises with physiotherapist
Maintain soft and regular bowel motions.
BMI > 25? Consider weight loss as treatment.

Question 7

Pharmacological management of urinary incontinence

Answer 7

Non-selective anti-muscarinic - Oxybutinin (ditropan) 5mg PO TDS / Tolterodine
M3 selective anti-muscarinic - Solifenacin 5mg PO OD
Vaginal oestrogen - Oestradiol pessary 10 microg weekly
beta adrenergic agonist - Mirabegron 25mg PO OD
Botox injection to bladder wall
SNRI - Duloxetine 30mg PO Daily (more for stress incontinence)

Question 8

Normal Bladder Habits

Answer 8

Health bladder can hold 300-400ml of urine during day and 800ml at night.
- Normal to pass urine 5-6x per day if you drink 6-8 glasses of fluid.