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PCNP Theory 3 2023 > Week 10 Menopause and Pelvic Floor Dysfunction > Flashcards

Week 10 Menopause and Pelvic Floor Dysfunction Flashcards

1
Q

Definition

Menopause

A

Permanent cessation of menses after 1 year of amenorrhea

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2
Q

Menopause symptoms

A
  • Bloating
  • Irritability
  • Mastalgia
  • Heavy menstrual bleeding
  • Vasomotor symptoms (hot flashes)
  • Insomnia
  • Migraines
  • PMS (premenstrual syndrome)
  • Vaginal dryness or discomfort
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3
Q

Classic symptom of menopause?
When most severe?

A

Hot flashes
Most severe in 1st 2 years (perimenopausal) → dramatic change

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4
Q

Who’s at higher risk of severe hot flashes

A
  • Surgically induced or chemically induced menopause (also known as chemopause)
  • African American ethnicity
  • Reduced physical activity
  • History of tobacco use
  • Higher BMI
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5
Q

1st line for menopause

A

Lifestyle changes
* Lowering the ambient temperature
* Using fans
* Exercise
* Avoiding triggers, e.g. alcohol, spicy foods
* Layering clothes

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6
Q

Pharm treatment for menopause (hot flashes)

A
  • 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
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7
Q

Hormone therapy: Estrogen & Progesterone
Considerations

A
  • 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
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8
Q

Menopausal hormone therapy for hot flashes - Caveats to minimize risk

A
  • 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

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9
Q

Contraindications for systemic estrogen therapy

A
  • Age > 60
  • High CV risk
  • Venous thromboembolism
  • History of breast cancer
  • Undiagnosed vaginal bleeding
  • Severe liver disease
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10
Q

Which antidepressants for hot flashes?

A

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
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11
Q

Other meds for hot flashes

A
  • 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.
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12
Q

Genitourinary syndrome of menopause (GSM)

A

Atrophic vaginitis
With time often worsens
Decreased estrogenation → thinning of epithelial layers leading to symptoms

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13
Q

GSM Vaginal symptoms

A
  • 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

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14
Q

Physical Exam appearance of GSM

A
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15
Q

GSM Diagnostics

A
  • Based on physical findings
  • Lab tests not necessary
  • Vaginal pH greater than 5
  • Wet prep and cervical cytology also show characteristic changes
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16
Q

GSM treatment

A
  • 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
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17
Q

GSM lifestyle management

A

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

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18
Q

Vaginal estrogen therapy: Tablet, Cream, ring
benefits
Estradiol options

A
  • 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)

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19
Q

Conjugated estrogen cream

A
  • 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
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20
Q

Trans consideration of using estrogen

A

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

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21
Q

Considerations for MEnopause and AFAB patients

A
  • 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)
22
Q

Menopause and Trans AMAB

A
  • 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!
23
Q

Stress incontinence

A

Complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.

24
Q

Overactive bladder
Which is not a symptom of overactive bladder?

A
  • 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
25
Q

Urge urinary incontinence

A

Complaint of involuntary leakage accompanied by or immediately preceded by urgency

26
Q

Risk factors and definition of overflow incontinence

A
  • “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!
27
Q

Acronym for Reversible causes of Incontinence

A
  • D Delirium
  • I Infection
  • A Atrophic urethritis/vaginitis
  • P Pharmacologic causes
  • P Psychological causes
  • E Excess fluid excretion
  • R Restricted mobility
  • S Stool impaction
28
Q

Medications that can affect lower UT function

A
29
Q

Functional Incontinence

A
  • Impairment of physical or cognitive function
  • Overactive bladder relative to access
  • Secondary gain
30
Q

Diagnostic testing

A
  • 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
31
Q

Lifestyle modifications for urinary incontinence

A
  • 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
32
Q

Behavioral modifications

A
  • 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
33
Q

Indications for Cystoscopy

A
  • 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
34
Q

Pelvic Floor Rehab: Kegel + Biofeedback
Can use for any incontinence

A
  • 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
35
Q

Overactive bladder Pharm Treatment

A

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

36
Q

SEs of OAB pharm tx

A

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

37
Q

Mirabegron (Myrbetriq)

A
  • 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

38
Q

OAB advanced tx

A

Botox - decrease spasms
Peripheral afferent nerve stimulation
Sacral Nerve stimulation

Surgery options: slings and injections

39
Q

Summar: Treatment of urge incontinence flow chart

A
  • 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)
40
Q

Types of fecal incontinence

A

o Leakage of gas
o Fecal seepage/Staining – without awareness
o Without awareness
o Urgency
o Overflow
o Secondary to rectal prolapse
o “Diarrhea”

41
Q

Things to consider in PE

A

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?

42
Q

Rectal Prolapse

A

First line tx: FIBER
FiberCon
Citrucel
Benefiber
Metamucil

43
Q

Pharm tx for rectal prolapse

A

Antidiarrheals: Imodium, Lomotil
Cholestyramine
Probiotics
Tincture of opiate
TCAs

44
Q

Causes of fecal incontinence

A

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

45
Q

Diagnostics Fecal Incontinence

A

o Anorectal manometry
o Pudenal Nerve Terminal Notor Latencies
o Endoanal U/S: Visualize integrity of Spincter complex

46
Q

Most common sphincter damage?

A

Vaginal delivery of baby
o Patients deteriorate with a second vaginal delivery
o Patients deteriorate with age
o Patients deteriorate with anorectal surgery

47
Q

Nonpharm tx of sphincter damage

A

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

48
Q

Takeaways for fecal incontinence

A

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

49
Q

Risk Factors of Pelvic Organ Prolapse

A

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

50
Q

PE Pelvic organ prolapse

A

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

51
Q

Management of prolapse

A

o Serial Observation
o Vaginal pessary
o Surgery

52
Q

Pessary Care

A

Local estrogen (Cream, VagiFem, Estring)
Pessary Check every 4-12weeks
Self-care - some take it out and wash
Replace pessary (discoloration and cracking)

PCNP Theory 3 2023 (7 decks)

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