Clinician's Guide Menopause Practice Chapter 4 Flashcards
(142 cards)
1
Q
What is the definition of the genitourinary syndrome of menopause (GSM)?
A
A collection of signs and symptoms associated with estrogen deficiency involving changes to the labia, introitus, vagina, clitoris, bladder, and urethra.
GSM includes genital, urinary, and sexual symptoms such as dryness, irritation, dysuria, and pain.
2
Q
What are the common symptoms associated with GSM?
A
- Genital symptoms: dryness, irritation, burning
- Urinary symptoms: dysuria, urgency, recurrent UTIs
- Sexual symptoms: dryness, pain
Symptoms must be bothersome for diagnosis and not caused by other conditions.
3
Q
What is vulvovaginal atrophy (VVA)?
A
A component of GSM affecting approximately 20% to 84% of menopausal women, characterized by atrophic changes in the vulvovaginal area.
VVA symptoms significantly impact women’s quality of life.
4
Q
What is the significance of a complete medical history in diagnosing vulvovaginal complaints?
A
It helps determine onset, duration, predominant symptom, prior treatment, and any possible underlying conditions.
A careful history can guide diagnosis and treatment.
5
Q
What should be included in a physical examination for vulvovaginal complaints?
A
- Evaluation of external genitalia, introitus, and perineum
- Check for plaques, lesions, and tenderness
- Assess vaginal atrophy and perform bimanual examination
This thorough examination helps identify any concomitant diseases or issues.
6
Q
True or False: Biopsy is necessary for any vulvar lesion that does not respond to treatment.
A
True.
Biopsy is essential for accurate diagnosis and to rule out malignancy.
7
Q
What factors can increase the risk of symptomatic VVA in women?
A
- Low estrogen levels from primary ovarian insufficiency
- Hypothalamic amenorrhea
- Prolonged lactation
- Cancer treatments such as chemotherapy or pelvic radiation
These conditions can lead to estrogen deficiency and associated symptoms.
8
Q
What are some nonhormone over-the-counter products for treating GSM?
A
- Vaginal moisturizers
- Vaginal lubricants
These products can provide relief from symptoms associated with GSM.
9
Q
Fill in the blank: Low-dose vaginal _______ therapy is highly effective if nonhormone interventions do not improve symptoms.
A
estrogen
Low-dose vaginal estrogen helps restore vaginal health and alleviate symptoms.
10
Q
What are the approved formulations for low-dose vaginal estrogen therapy?
A
- Vaginal ring
- Tablets
- Creams
These formulations are effective for treating VVA and are minimally absorbed.
11
Q
What is the purpose of pelvic floor physical therapy (PT) in treating severe GSM?
A
To increase pelvic floor muscle tone and address issues like provoked pelvic floor hypertonus.
PT can be effective in treating discomfort and dyspareunia associated with GSM.
12
Q
What is the recommended dosing for estradiol vaginal tablets?
A
10 µg placed in the vagina twice weekly after an initial nightly use of 2 weeks.
This regimen helps in managing VVA symptoms.
13
Q
What is a common side effect of using lubricants and moisturizers for vaginal health?
A
Vulvar irritation or contact dermatitis may occur if allergic to components.
Women may need to try different formulations to find a suitable product.
14
Q
What additional benefit does the 17β-estradiol vaginal ring provide?
A
It is FDA approved for the treatment of urinary urgency.
This makes it a dual-purpose option for managing both vaginal and urinary symptoms.
15
Q
What is the FDA-approved initial dosage of 17β-estradiol cream for VVA?
A
2-4 g/day for 1-2 weeks
VVA stands for vulvovaginal atrophy
16
Q
What is the maintenance dosage of 17β-estradiol cream for VVA?
A
1 g one to three times a week
17
Q
What are the typical doses of estrogen cream used in clinical practice?
A
0.5-1 g/day used two to three times weekly
18
Q
What does FDA stand for?
A
US Food and Drug Administration
19
Q
What is the recommended initial dosage of conjugated estrogens Premarin Vaginal Cream for VVA?
A
0.5-2 g/day for 21 days, then off for 7 days
20
Q
What is the dosage of Estragyn Vaginal Cream?
A
2-4 g/day
21
Q
What device contains 2 mg of 17β-estradiol and releases approximately 7.5 µg/day?
A
Estring
22
Q
What is the active ingredient in Vagifem vaginal tablets?
A
Estradiol hemihydrate
23
Q
What is the initial dosage of Vagifem for VVA?
A
1 tablet/day for 2 weeks
24
Q
True or False: Low-dose vaginal ET is contraindicated for women with a history of CVD.
A
False
25
What hormone is approved for the treatment of moderate to severe dyspareunia secondary to VVA?
Dehydroepiandrosterone (DHEA)
26
What is the dosage of intravaginal DHEA shown to improve symptoms in clinical trials?
0.5% daily for 12 weeks
27
What is ospemifene classified as?
A selective estrogen-receptor modulator (SERM)
28
Fill in the blank: The use of _______ therapy for GSM remains controversial.
laser
29
What is a common reason women remain untreated for GSM?
Lack of awareness that VVA is a medical condition
30
What percentage of women in a study sought treatment for vulvodynia?
48.6%
31
What is vulvodynia?
Vulvar pain of at least 3 months' duration without a clear identifiable cause
32
What are the classifications of vulvodynia based on pain site?
* Localized
* Generalized
* Mixed
33
What are some common causes of vulvar pain?
* Infectious
* Inflammatory
* Neoplastic
* Neurologic
* Trauma
* Iatrogenic
* Hormone deficiencies
34
What is the prevalence range of chronic vulvar pain?
3% to 15%
35
What are care measures to minimize vulvar irritation?
* Wear 100% cotton underwear
* Clean the vulva with water only
* Use mild soaps for bathing
* Apply a preservative-free emollient
* Use adequate lubrication for intercourse
36
What should women using low-dose vaginal ET be informed about?
To report any vaginal bleeding, even spotting
37
What is the potential risk associated with low-dose vaginal ET?
Endometrial hyperplasia
38
What should be avoided to minimize vulvar irritation?
Vulvar irritants (perfumes, dyes, shampoos, detergents) and douching
39
What types of therapies are suggested for vulvodynia?
Topical anesthetics, estrogen, testosterone, oral antidepressants, anticonvulsants, injectable medications, biofeedback, vaginal dilators, pelvic floor PT, cognitive-behavioral therapy, botulism toxin, transcutaneous electric nerve stimulation
40
What is the recommended duration for trying medical therapies for vulvodynia before reassessment?
3 to 6 weeks
41
What is vulvovaginitis most commonly caused by?
Candida, bacterial vaginosis (BV), sexually transmitted infections (STIs) like trichomoniasis, gonorrhea, or chlamydia
42
What are the characteristics of discharge in different types of vaginitis?
* Yeast vaginitis: White, thick, clumpy
* Bacterial vaginosis: Gray-yellow
* Trichomonas infection: Yellow-green, frothy or bubbly
* Irritant/Allergy: Clear
43
What is the most common cause of yeast vaginitis?
Candida albicans
44
What percentage of women will develop symptomatic vulvovaginal candidiasis at least once in their lives?
Approximately 75%
45
What are the common symptoms of yeast vaginitis?
Itching, thick clumpy white discharge, vulvar erythema, excoriations
46
What is classified as complicated yeast vaginitis?
* Infection in an immune-compromised host
* Caused by a nonalbicans species
* Considered recurrent
47
What is the treatment for recurrent vulvovaginal candidiasis?
10 to 14 days of induction therapy with topical agent or oral fluconazole followed by fluconazole 150 mg weekly for 6 months
48
What is bacterial vaginosis (BV) caused by?
An imbalance in vaginal microflora, lack of hydrogen peroxide-producing lactobacilli, overgrowth of anaerobic organisms
49
What are the Amsel criteria for diagnosing bacterial vaginosis?
* Abnormal thin gray discharge
* Vaginal pH > 4.5
* Fishy amine odor with 10% hydrogen peroxide (whiff test)
* > 20% clue cells on saline microscopy
50
What is the recommended treatment for bacterial vaginosis?
Oral or vaginal metronidazole or clindamycin
51
What is trichomoniasis caused by?
Trichomonas vaginalis
52
What are the symptoms of trichomoniasis?
Copious frothy yellow to green discharge, dyspareunia, vulvovaginal soreness, bladder symptoms
53
What is desquamative inflammatory vaginitis often associated with?
Hypoestrogenic states (postpartum, perimenopausal, postmenopausal)
54
What is lichen sclerosis?
A vulvar inflammatory disease of unknown etiology, often immune-mediated
55
What are the clinical features of lichen sclerosis?
* White papules and plaques
* Purpura
* Hyperkeratosis
* Fissures
* Ulcerations
56
What is the risk of developing squamous cell carcinoma in lichen sclerosis patients?
Approximately 5%
57
What are the variants of lichen planus that can affect the vulva?
* Classic (papulosquamous)
* Hypertrophic
* Erosive
58
What is lichen simplex chronicus?
A common chronic inflammatory condition of the vulva causing intense pruritus
59
What are the common irritants that can cause contact dermatitis?
* Soap
* Laundry detergent
* Toilet paper
* Vaginal moisturizers and lubricants
* Sanitary and incontinence pads
60
What is the typical presentation of vulvar psoriasis?
Pink, smooth, glossy plaques in intertriginous areas, often coexisting with systemic disease
61
What is the immunologic origin of allergic dermatitis?
Occurs when an irritative substance contacts the vulva, causing immediate reactions such as stinging or pruritus.
## Footnote
Common irritants include soap, laundry detergent, toilet paper, vaginal moisturizers, lubricants, and sanitary pads.
62
What is contact dermatitis?
Occurs due to fleeting or chronic contact with irritative substances, leading to immediate reactions.
## Footnote
Common irritants include soap, laundry detergent, and sanitary pads.
63
How long after exposure does allergic dermatitis occur?
36 to 48 hours after exposure to the allergen.
64
What are common treatments for allergic dermatitis?
Topical lubricating agents, protective barriers, and topical corticosteroids.
65
What is seborrheic dermatitis?
A chronic skin condition that manifests in areas with concentrated sebaceous glands, characterized by pale to yellow-red lesions covered with an oily scale.
66
What is vulvar intraepithelial neoplasia (VIN)?
A classification for HPV squamous cell lesions, introduced by the International Society for the Study of Vulvovaginal Disease in 2015.
67
What types of lesions are associated with vulvar low-grade squamous intraepithelial lesions?
Associated with genotypes 6 and 11.
68
What is the risk associated with vulvar high-grade squamous intraepithelial lesions?
Considered a precancerous condition.
69
Who is more likely to develop vulvar high-grade squamous intraepithelial lesions?
Women who smoke, are immunocompromised, or have other HPV high-risk conditions.
70
What is the recommended treatment for differentiated VIN?
Wide, local excision.
71
What is the most common complaint among women with VIN?
Pruritus.
72
What is the average age of diagnosis for vulvar cancer?
68 years.
73
What percentage of vulvar cancers are squamous-cell carcinoma?
75% to 80%.
74
What is the most common type of vulvar cancer?
Squamous-cell carcinoma.
75
What is extramammary Paget disease?
An intraepithelial adenocarcinoma of the vulva, accounting for 1% to 2% of vulvar malignancies.
76
What is the common treatment for Bartholin gland abscesses?
Incision, drainage, or marsupialization.
77
What are epidermal inclusion cysts characterized by?
Subcutaneous, smooth, mobile, and nontender lesions.
78
What is the common cause of condylomata acuminatum?
Human Papillomavirus (HPV).
79
What are the nonpharmacologic strategies for preventing urinary tract infections?
* Void after intercourse
* Wipe from front to back
* Avoid soaps or perfumed products
* Consume cranberry extract or juice.
80
What is the prevalence range of urinary incontinence in midlife women?
5% for severe incontinence to 60% for mild incontinence.
81
What is stress incontinence?
Involuntary loss of urine with activities that increase intra-abdominal pressure.
82
What is urgency incontinence?
Involuntary loss of urine preceded by a sensation of urgency to urinate.
83
What is mixed incontinence?
Includes symptoms of both stress and urgency incontinence.
84
What is extraurethral incontinence?
Result of an abnormal opening from the bladder, such as a vesicovaginal fistula.
85
What is the association between menopause and urinary incontinence?
Women report mild incontinence symptoms in early perimenopause, but symptoms decline in the first 5 years after menopause.
86
What factors may be associated with urinary incontinence?
* Age
* Diabetes Mellitus
* Obesity
* Weight gain
* Parity
* Depression
* Hysterectomy.
87
What is extraurethral incontinence?
Extraurethral incontinence is the result of an abnormal opening from the bladder, such as a vesicovaginal fistula, and is the least common type of incontinence.
## Footnote
It may occur as a complication of bladder injury during a hysterectomy.
88
What percentage of midlife and older women report having urinary incontinence?
Up to half of midlife and older women report having urinary incontinence.
89
What are some common reasons women do not seek care for urinary incontinence?
* Embarrassment
* Misconception that incontinence is normal
* Lack of awareness about treatment options
* Healthcare providers not asking about it
90
Why is determining the causes and types of urinary incontinence important?
It is important for individualizing treatment.
91
What is one of the best tools to evaluate urinary incontinence complaints?
A 3-day urinary diary.
92
What should a urinary diary include?
* Type and amount of fluid intake
* Circumstances of each leakage episode
* Amount of urine leaked
* Use of external protection
* Amount of urine voided
93
What is considered a normal postvoid residual urine volume?
A postvoid residual of 100 mL or less is considered normal.
94
What initial laboratory test should be performed for urinary incontinence evaluation?
A urinalysis.
95
What can the presence of hematuria suggest?
It may suggest bladder pathology such as bladder stone or bladder cancer.
96
What is a common misconception about chronic dampness of underwear?
It is sometimes mistaken for incontinence when the cause is increased vaginal secretions or perineal perspiration.
97
What should be addressed first in the treatment of mixed incontinence?
The most troublesome or dominant symptom.
98
Name a strategy for managing stress incontinence.
* Incontinence pads
* Fluid restriction
* Weight loss
* Timed voiding
99
What is a recommended fluid intake limit to reduce leakage episodes?
Limiting total fluid intake to about 64 oz per day.
100
What type of exercises can improve stress incontinence?
Pelvic floor exercises, commonly called Kegels.
101
What is the success rate range for minimally invasive surgical procedures for stress incontinence?
62% to 98% success rate.
102
What medication is commonly used off-label in the US for nocturnal urgency incontinence?
Imipramine HCl.
103
What is the primary purpose of antimuscarinic agents in urgency incontinence treatment?
To decrease the frequency and intensity of detrusor contractions.
104
What is sacral neuromodulation stimulation?
A system that stimulates the sacral nerve root to modulate neural reflexes influencing bladder storage and emptying.
105
What is the therapeutic success rate for sacral neuromodulation stimulation?
As high as 83%, depending on the definition of improvement.
106
What is the role of botulinum A injections in treating urge incontinence?
To provide an option for women whose urge incontinence does not respond to basic treatments.
107
What is an impulse generator in relation to urge incontinence?
A surgically implanted device under the skin in the upper buttock area attached to leads in the sacral nerve space at S3.
108
What is the therapeutic success rate for impulse generator treatment?
As high as 83%, depending on the definition of improvement.
109
What is the average reduction in leaking episodes per day after impulse generator treatment?
From 8.8 to 2.3 per day.
110
What treatment option is available for women whose urge incontinence does not respond to basic treatments?
Botulinum A injections via cystoscopy.
111
What percentage of women experience improvement from Botulinum A injections?
About 60%.
112
When should a woman be referred to a urologist or urogynecologist?
For complex problems such as neurologic conditions, pelvic organ prolapse, or failure of nonsurgical treatments.
113
What defines Overactive Bladder (OAB) syndrome?
Idiopathic urinary urgency (with or without incontinence) with urinary frequency (>8 voids/24 h) and sometimes nocturia.
114
What is the estimated prevalence of OAB symptoms in the population?
About 12%.
115
How does the incidence of OAB symptoms change with age?
The incidence increases with age.
116
What is a urinary diary used for in the evaluation of OAB syndrome?
To detail fluid intake and number of voids during the day and night.
117
What is nocturia defined as?
Voiding more than two times per night.
118
What are common management strategies for Overactive Bladder syndrome?
* Restricting fluids
* Avoiding caffeine
* Improving mobility or toilet access
* Pelvic floor exercises and bladder retraining
* Medications
* Acupuncture
* Sacral neuromodulation stimulation
119
What main adverse events are associated with anticholinergic medications for OAB syndrome?
Dry mouth and constipation.
120
What is the role of vaginal estrogen in the treatment of urinary urgency symptoms?
It appears to be effective in a subset of postmenopausal women.
121
What is the prevalence of pelvic organ prolapse among women?
Between 3% and 8% report symptoms or signs of prolapse.
122
What are risk factors for pelvic organ prolapse?
* Aging
* Parity
* Obesity
* Hysterectomy
123
What is anal incontinence defined as?
Loss of anal sphincter control leading to involuntary leakage of gas or stool.
124
What percentage of community-dwelling women report anal incontinence?
Approximately 9%.
125
What are some conservative treatments for anal incontinence?
* Dietary changes
* Medications
* Pelvic floor physical therapy
126
What is functional constipation?
Common problems of defecation including straining, incomplete evacuation, and constipation.
127
What is the primary management for anal fissures?
Treatment for constipation.
128
What symptom is most commonly associated with anal fissures?
Tearing pain with passage of hard bowel movements.
129
What diagnostic tests may be indicated for women with anal incontinence who do not respond to conservative treatment?
* Colonoscopy
* Endoanal ultrasonography
130
What is the primary symptom of anal fissures?
Tearing pain with passage of hard bowel movements
## Footnote
This pain is most commonly located posteriorly and midline.
131
What is the primary management for anal fissures?
Treatment for constipation
## Footnote
Additional methods include warm sitz baths.
132
What topical analgesic is commonly used for anal fissures?
Lidocaine jelly 2%
## Footnote
This helps to alleviate pain.
133
What topical vasodilators can be used for anal fissures?
Compounded nifedipine 0.2% or 0.3% ointment
## Footnote
These help to relax the anal sphincter.
134
What is the prevalence of symptomatic hemorrhoids in women outside of pregnancy?
About 4.4%
## Footnote
This prevalence peaks around midlife.
135
What percentage of patients reporting anal symptoms are diagnosed with hemorrhoids?
One-quarter
## Footnote
This includes symptoms like itching, burning, and pain.
136
What are the cardinal symptoms of hemorrhoids?
* Rectal bleeding associated with defecation
* Anal pruritis
* Anal pain
## Footnote
These symptoms are key indicators of hemorrhoids.
137
How can hemorrhoids be classified based on their location?
* External (distal to the dentate line)
* Internal (proximal to the dentate line)
* Mixed
## Footnote
Internal hemorrhoids are graded from I to IV based on prolapse.
138
What is the primary management of hemorrhoids?
Treatment of the inciting cause, most often constipation
## Footnote
This involves assessment for other causes of rectal bleeding and anal symptoms.
139
What topical agents can be used for hemorrhoids?
Lidocaine/hydrocortisone cream
## Footnote
These are used as analgesic and anti-inflammatory agents.
140
What dietary recommendations are made for managing functional constipation?
* Ensure adequate fluid intake
* Ensure adequate fiber intake (20-35 g/d)
## Footnote
Adequate hydration and fiber are key components.
141
What types of laxatives are recommended for constipation?
* Bulk-forming laxatives (e.g., psyllium)
* Surfactants/Stool softeners (e.g., docusate sodium)
* Osmotic agents (e.g., polyethylene glycol)
* Stimulant laxatives (e.g., bisacodyl)
## Footnote
Stimulant laxatives are best used for acute constipation.
142
What might indicate the need for surgical treatment of hemorrhoids?
* Severe pain from thrombosed hemorrhoids
* Irreducible internal hemorrhoids
## Footnote
Women with hemorrhoids that do not respond to conservative treatment may require referral.
