Week 10 Menopause and Pelvic Floor Dysfunction Flashcards
Definition
Menopause
Permanent cessation of menses after 1 year of amenorrhea
Menopause symptoms
- Bloating
- Irritability
- Mastalgia
- Heavy menstrual bleeding
- Vasomotor symptoms (hot flashes)
- Insomnia
- Migraines
- PMS (premenstrual syndrome)
- Vaginal dryness or discomfort
Classic symptom of menopause?
When most severe?
Hot flashes
Most severe in 1st 2 years (perimenopausal) → dramatic change
Who’s at higher risk of severe hot flashes
- Surgically induced or chemically induced menopause (also known as chemopause)
- African American ethnicity
- Reduced physical activity
- History of tobacco use
- Higher BMI
1st line for menopause
Lifestyle changes
* Lowering the ambient temperature
* Using fans
* Exercise
* Avoiding triggers, e.g. alcohol, spicy foods
* Layering clothes
Pharm treatment for menopause (hot flashes)
- Hormone therapy
- either combined estrogen/progesterone, or estrogen alone for persons with no uterus – cause endometrial dysplasia
- No uterus - only estrogen
- Nonhormonal pharmacotherapy
- Cognitive Behavioral Therapy &
- Clinical hypnosis - not widely used
- Vitamin E – similar efficacy as placebo
Hormone therapy: Estrogen & Progesterone
Considerations
- Intact uterus: unopposed systemic estrogen can cause endometrial hyperplasia; progesterone will prevent this. (IF INTACT UTERUS)
- Can administer PO combination or patch
- Can also do estrogen patch with oral progesterone
- For persons s/p hysterectomy; estrogen alone ok
Menopausal hormone therapy for hot flashes - Caveats to minimize risk
- Limit exposure to shortest treatment time needed
- Use transdermal (patch) for lower risk of venous thromboembolism
- Taper slowly over 6-12 months to minimize severity and frequency of hot flashes
- Prescribe lower dose, particularly in patients with obesity
Of note: low dose will take longer to work, 8-12weeks
Contraindications for systemic estrogen therapy
- Age > 60
- High CV risk
- Venous thromboembolism
- History of breast cancer
- Undiagnosed vaginal bleeding
- Severe liver disease
Which antidepressants for hot flashes?
SSRIs (selective serotonin uptake inhibitors)
SNRIs (serotonin norephinephrine reuptake inhibitors)
* Target NTs in the hypothalamic thermoregulation center
- Paroxetine (Paxil) contraindicated for women on tamoxifen; blocks metabolism 10 to 25 mg daily
- Venlafaxine (Effexor) – but risk of GI SE (n/v); start with 37.5 mg and titrate up to 75 mg daily
- Desvenlafaxine (Pristiq, Khedezla) – similar but no need to titrate up; 100 to 150 mg daily
Added benefit: people with hot flashes have double the risk of depression; antidepressant therapy can help both with mood disturbances and hot flashes, a twofer
Other meds for hot flashes
- Gabapentin – UpToDate suggests start at 100 to 300 mg a night and titrate up
- Pregabalin – 150 mg to 300 mg; more expensive, similar side effects
- For both of the above gabapentinoids, start low and titrate up
- Clonidine patch – hypotension; rebound hypertension, dry mouth; constipation; dizziness; sedation – not used much these days
- Clonidine prescribed for women who have hot flashes and high blood pressure, especially when other HTN meds have not worked well.
Genitourinary syndrome of menopause (GSM)
Atrophic vaginitis
With time often worsens
Decreased estrogenation → thinning of epithelial layers leading to symptoms
GSM Vaginal symptoms
- Vaginal dryness
- Burning
- Pruritus
- Discharge
** Bleeding- should evaluate (could be vaginal or uterine)** - Dyspareunia/Bleeding after sex
- Petechiae
- Ulceration
- Perineal pressure sensation
- Infection/Leukorrhea
- Inflammation
Urinary Symptoms
* Urethral discomfort
* Frequency
* Hematuria
* Dysuria
* Increased incidence of UTIs
* Likely contribute to stress incontinence
Physical Exam appearance of GSM
GSM Diagnostics
- Based on physical findings
- Lab tests not necessary
- Vaginal pH greater than 5
- Wet prep and cervical cytology also show characteristic changes
GSM treatment
- Lowest dose?
-
First line: nonhormonal moisturizers for mild symptoms (Replens); use every 3 days
- If not satisfactory, hormonal therapy needed
- Vaginal estrogen therapy is first choice for moderate to severe symptoms of GSM
- Any water based, unscented, non warming moisturizer
- Also use oils – olive oil, coconut oil
GSM lifestyle management
Sexual activity – people who are sexually active have fewer symptoms
* Improved blood flow; higher androgen and gonadotropin levels
* Don’t make assumptions of their sexual activity level
Smoking Cessation
* Smoking lowers estrogen levels
* Smoking affects vaginal epithelium, decreases blood perfusion, and increases atrophic changes
Vaginal estrogen therapy: Tablet, Cream, ring
benefits
Estradiol options
- Increases vaginal secreations
- Fewer UTIs
Estradiol tablet (Vagifem, 10 mcg) , introduced with applicator; once nightly for 2 weeks, then twice a week thereafter
Estradiol estrogen cream (Estrace)
Conjugated estrogen cream
- Can be applied directly to vulva
- Twice weekly low dose cream as effective as tablets
- However, quantity not as controlled
- Thickened vaginal lining, decreased dyspareunia, no cases of endometrial carcinoma for one year during various studies; appears safe
Trans consideration of using estrogen
Reassure trans patients on testosterone that vaginal estrogen is localized and will not reverse masculinization
* Also consider warning them about the brand name “Vagifem” as this may trigger dysphoria or just be embarrassing for them to pick up
* May prefer the ring as it requires less frequent contact with genitals
Considerations for MEnopause and AFAB patients
- If no hormones or oophorectomy, will undergo same changes as cis women
- May have tougher time because of the gendered way we think about menopause
- If taking testosterone but ovaries still present, may consider discontinuing testosterone around age 50 (per UCSF); however, discontinuing testosterone will cause some loss of virilization, and may cause menopausal symptoms
- Virilization – masculinization; male physical characteristics (muscle, voice change, body hair)
Menopause and Trans AMAB
- If taking estrogen, may consider discontinuing around age 50 d/t cardiovascular risks (per UCSF; no evidence for either continuation or cessation)
- If post-orchiectomy, this may cause menopausal symptoms, and increases osteoporosis risk
- If testicles remain, virilization may occur
- Shared decision-making with patient!
Stress incontinence
Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.
Overactive bladder
Which is not a symptom of overactive bladder?
- When urinary **frequency **(daytime and nighttime) and urgency, with or without urgency incontinence, in the absence of UTI or other obvious pathology is **self-reported as bothersome. **
- DYSURIA
Urge urinary incontinence
Complaint of involuntary leakage accompanied by or immediately preceded by urgency
Risk factors and definition of overflow incontinence
- “any involuntary loss of urine associated with overdistention of the bladder”
- Recent bladder suspension procedure – swelling involved → overflow
- Neurologic disease (e.g. CVA, MS)
- Diabetes
- Severe prolapse
- Having a prostate!
Acronym for Reversible causes of Incontinence
- D Delirium
- I Infection
- A Atrophic urethritis/vaginitis
- P Pharmacologic causes
- P Psychological causes
- E Excess fluid excretion
- R Restricted mobility
- S Stool impaction
Medications that can affect lower UT function
Functional Incontinence
- Impairment of physical or cognitive function
- Overactive bladder relative to access
- Secondary gain
Diagnostic testing
- Post-void residual – straight cath + U/S
- Urinalysis and culture
- Cough stress test – empty bladder
- Cough → see if there’s urine when in supine
- Simple office cystometry: putting fluid
- Tests bladder
- sensation
- capacity
- detrusor function
- Inexpensive and easily performed
- Useful for preliminary diagnosis
- Uroflowmetry
- Urodynamics
Lifestyle modifications for urinary incontinence
- Smoking cessation
- Reduction of constipation
- Avoid excess fluids
- Reduction of caffeine, carbonated beverages, diet beverages, and alcohol
- Acidic foods
- Have patient keep a food diary to determine what foods influence their bladder
Behavioral modifications
- Void only at scheduled times
- Slowly increase interval between voids
- Suppress urgency between intervals
- Conscious effort to suppress sensory stimuli
- Requires motivated patient and health care provider
- no reported side effects
- do not limit future treatment options
Indications for Cystoscopy
- recurrent UTIs
- hematuria
- urgency/frequency in older patient
- r/o urethral diverticulum
- painful bladder (r/o interstitial cystitis)
- recurrent urinary incontinence – symptoms resolved then come back
- ? routine evaluation of urinary incontinence
Pelvic Floor Rehab: Kegel + Biofeedback
Can use for any incontinence
- Kegel exercises
- Increased muscle tone
- Complete resolution in 20% of patients
- 50%-75% symptom reduction in most patients
- Biofeedback
- Various devices for home and office use
- Surface or needle electrodes (electromyography) to determine muscle contractility
- Vaginal or anal probes and EMG sensors to monitor pressure and contractility
Overactive bladder Pharm Treatment
Short acting
- Oxybutynin RI 5 or 2.5-5 mg BID-TID
- Tolterodine 1 or 2 mg BID
- Trospium 20 mg PO BID
Extended release
- Oxybutynin XL (Ditropan) 5, 10, 15 mg QD
- Tolterodine LA (Detrol) 2 or 4 mg QD
- Oxybutynin patch (Oxytrol) 3.9 mg/day
- Solifenacin (Vesicare) 5-10 mg PO QD
- Darifenacin (Enablex) 7.5 – 15 mg PO QD
- Trospium XR (Sanctura) 60 mg QD
- Fesoterodine (Toviaz) 4 – 8 mg PO QD
- Oxybutynin gel (Gelnique) 1 sachet topically QD
SEs of OAB pharm tx
Caution
o Narrow-angle glaucoma (untreated)
o GERD
o Prolonged QT syndrome
o Urinary retention
Side Effects
o Constipation
o Xerostomia (dry mouth)
o Xerophthalmia (dry eyes)
o Blurry vision
o Urinary retention
o Cognitive abnormalities
Mirabegron (Myrbetriq)
- Beta 3 adrenergic receptor agonist
- Relaxes detrusor smooth muscle
- Modest benefit
- Lack of long-term data on efficacy and safety
- Caution in untreated hypertension
- Second-line treatment
More tolerable vs. anticholinergics
OAB advanced tx
Botox - decrease spasms
Peripheral afferent nerve stimulation
Sacral Nerve stimulation
Surgery options: slings and injections
Summar: Treatment of urge incontinence flow chart
- Incontinence is a common problem
- Get the type!
- Many forms are treatable
- medication, non surgical and surgical
- Important to figure out type of incontinence first
- stress, urge, mixed, other
- Treatment is determined by etiology.
- Lifestyle modifications
- Biofeedback/Physical therapy
- Medications
- Pessary
- Surgical repair
- Sacral nerve stimulation
-
ADDITIONAL NOTE
- If no improvement in symptoms, consider pelvic u/s (R/O ovarian cancer)
Types of fecal incontinence
o Leakage of gas
o Fecal seepage/Staining – without awareness
o Without awareness
o Urgency
o Overflow
o Secondary to rectal prolapse
o “Diarrhea”
Things to consider in PE
Evaluate the anatomy
o How does the skin look
o Any skin tags or hemorrhoids
o Any protrusions
o Is the anus open or closed
Feel
o Do a rectal exam!
o Evaluate for masses
o Evaluate tone
o Is there stool there?
Rectal Prolapse
First line tx: FIBER
FiberCon
Citrucel
Benefiber
Metamucil
Pharm tx for rectal prolapse
Antidiarrheals: Imodium, Lomotil
Cholestyramine
Probiotics
Tincture of opiate
TCAs
Causes of fecal incontinence
Anal sphincter weakness
o Obstetric trauma
o Anorectal surgery
o Scleroderma
o Internal sphincter thinning of unknown etiology
Anatomical disturbances of pelvic floor
o Rectocele
o Rectal prolapse
o Internal intussusception
Inflammatory conditions / diarrhea
Central nervous system disease / neuropathy
Diagnostics Fecal Incontinence
o Anorectal manometry
o Pudenal Nerve Terminal Notor Latencies
o Endoanal U/S: Visualize integrity of Spincter complex
Most common sphincter damage?
Vaginal delivery of baby
o Patients deteriorate with a second vaginal delivery
o Patients deteriorate with age
o Patients deteriorate with anorectal surgery
Nonpharm tx of sphincter damage
Short-term and long-term results of Sphincteroplasty
Short term: usually great results
Long-term: gain incontinence of solid stool
Biofeedback: Sphincter Strengthening
o Manometry guided muscle strengthening exercises
o EMG stimulation of anal sphincter
o Sensitivity Re-Training
When all else fails: stomas → but have issues too
Conclusions
o Incontinence is a common problem
o Can occur in both men and women; most common in women
o Many forms are treatable surgically.
o Surgical treatment is determined by etiology.
o Testing helps define best treatment
Takeaways for fecal incontinence
Regularize Bowel Movements
o High Fiber Diet
o Tap water enemas
Treat loose bowel movements/diarrhea
o Immodium
o Cholestyramine
Strengthen Sphincter Function
o Kegel Exercises
o Biofeedback
No Improvement
o Refer
Risk Factors of Pelvic Organ Prolapse
o Ethnicity or race: Hispanic, white
o General: Advancing age (decreased estrogenation), parity, elevated BMI, connective tissue disorders (e.g., Ehlers-Danlos syndrome)
o Genetics: Family history of prolapse
o Increased intraabdominal pressure: Chronic cough, constipation, repeated heavy lifting
o Obstetric: Operative vaginal delivery, vaginal delivery
o Previous surgery Hysterectomy/previous prolapse surgery
PE Pelvic organ prolapse
Pelvic examination
o Hypoestrogenism
o Loss of rugae
o Pale, translucent epithelium
o Urethral caruncle
Speculum exam (Posterior blade)
o POP-Q exam – mostly used for research or for progression over time
o Anterior compartment
o Posterior compartment
o Apical compartment
Erect rectovaginal examination
Management of prolapse
o Serial Observation
o Vaginal pessary
o Surgery
Pessary Care
Local estrogen (Cream, VagiFem, Estring)
Pessary Check every 4-12weeks
Self-care - some take it out and wash
Replace pessary (discoloration and cracking)
