Session 10

Question 1

1. Define menapause

Answer 1

1. no menstrual periods for 12 consecutive months and no other biological or physiological cause can be identified

permanent cessation of menstruation at the end of reproductive life due to loss of ovarian follicular activity

Question 2

INCIDENCE OF MENOPAUSE

1. Physiologic menopause:
2. Pathologic menopause:
3. The menopause phase is usually broken down into four categories:
4. Define these phases

Answer 2

1. – The normal decline in ovarian function due to ageing begins in most women between ages 45 and 55 on average 50

– result in infrequent ovulation,

– decreased menstrual function and eventually cessation of menstruation

2. gradual or abrupt cessation of menstruation before 40 years
3. – Pre-menopause
   – Peri-menopausal (transition menopause)
   – Menopause
   – Post menopause

Question 3

What causes the reduction in oestrogen?

State how STEROID AND PITUITARY HORMONES change in peri - menopause

Answer 3

Reproductive life ~400 of the primordial follicles grow into mature follicles and ovulate.

• ~45 years old only a few primordial follicles remain to be stimulated by FSH and LH
• The production of oestrogen by ovaries decreases as the number of primordial follicles approaches zero
• When oestrogen production falls below a critical value the oestrogens can no longer inhibit production of gonadotrophins (FSH and LH)

2. IMAGE

Question 4

1. Cause of menapause?
2. What is this image showing

Answer 4

1. • Ovaries are totally depleted of follicles and no amount of stimulation from gonadotrophins can force them to work
   • i.e primary ovarian failure
   • Cessation of menstrual cycles
   • Average age ~50, but variable
   • No more follicles to develop
   • Oestrogen levels fall dramatically
   • FSH & LH levels rise, FSH dramatically
   – No inhibin
2. GONADOTROPHINS DURING MENOPAUSE

Question 5

1. What hormone do we measure for menapause and why?

Answer 5

1. FSH!!!

oestrogen can be made from adipose tissue by aromatase

Question 6

CONSEQUENCES OF OESTROGEN DEFICIENCY

Answer 6

Unopposed oestrogen -> aromatase in adipose still producing oestrogen

thus spotting as proliferation of endometrium and no progesterone to cause the shedding of the endometrial lining

Osteoporosis - inc osteoclasts

sudden temp changes - palpitations

Question 7

Effects of menopause on the vasomotor system

Answer 7

Effects 80%

Relieved by oestrogen treatment

during night

transiet warmth to intense heat

Question 8

Describe the types of dysfunctional uterine bleeding (DUB) and the cause

Answer 8

Dysfunction uterine bleeding
– Spotting between cycles
– Extremely heavy bleeding
– Mid-cycle bleeding
– Longer, shorter, or unpredictable lengths of time between periods
– Longer, shorter, or unpredictable durations of periods

Why? continued oestrogen (aromatase)
– causes the endometrium to keep thickening
– leads to a late menstrual period followed by irregular bleeding and spotting.
– greater thickening called “hyperplasia,”
– No corpus luteum = no progesterone
– Increased risk of carcinoma (unopposed oestrogen)

Question 9

1. Why is progesterone low?
2. What are the psychological changes in menopause?

Answer 9

1. No follicles

no ovulation

no corpus luteum formed -> No progesterone

2. Insomnia more due to vasomotor changes

The psychological changes are mainly manifested by
– frequent headache,
– irritability,
– fatigue,
– depression and insomnia .
– Although these are often said to be due to changes in the hormonal levels, they are more likely to be related to the loss of sleep due to night sweat.
– Diminished interest in sex may be due to emotional upset or may be secondary to painful intercourse due to a dry vagina.

Question 10

1. CHANGES IN THE GENITAL ORGANS (OVARY)?

Answer 10

1. The ovaries become smaller (atrophic)
   – oestrogen production ↓
   – produced small amount of androgen during reproductive life
   – Important as aromatase converts androgens to oestrogens in ovary and adipose tissue
   – after menopause the substantially increased gonadotropin levels maintain ovarian androgen secretion despite substantial oestrogen demise

Oestrogen levels go down

testosterone levels continue due to androgen release

Question 11

CHANGES IN GENERAL APPEARANCE -> (ayushi what is fucked up in your appearance)

Answer 11

Skin: The skin loses its elasticity and becomes thin and fine. This is due to the loss of elastin and collagen from the skin.

Weight: increase is more likely to be the result of irregular food habit due to mood swing. There is more deposition of fat around hips, waist and buttocks.

Hair: dry & coarse after menopause . There may hair loss due to the decreasing level of oestrogen.

Voice: deeper due to thickening of vocal cords

Question 12

1. DIGESTIVE AND URINARY SYSTEMS

Answer 12

1. • Motor activity diminished after menopause - constipation

• Urinary system: oestrogen level decreases - tissue lining the urethra and the bladder become drier, thinner and less elastic:

– Changes in bladder loss of pelvic tone

– Urinary incontinence

– increased frequency of passing urine + increased tendency to develop UTI

Question 13

1. CHANGES IN THE GENITAL ORGANS (UTERUS)
2. CHANGES IN THE EXTERNAL GENITAL ORGANS

Answer 13

1. • becomes small and fibrotic due to atrophy of the muscles after the menopauses

(Regression of endometrium & shrinkage of myometrium)

• The cervix become smaller and appears to flush with vagina. In older women the cervix may be impossible to identify separately from vagina

– Thinning of cervix

– Vaginal rugae lost

2. Vulva
   – The fat in the labia majora and the Mons pubis decreases and pubic hair become spare

Breast
– In thin built women the breast become flat and shrivelled
– In heavy built women they remain flabby and pendulous

Question 14

What changes occur to bone?

Answer 14

• Calcium loss from the bone is increased in the first five years after the onset of menopause, resulting in a loss of bone density

• The calcium moves out of the bones, leaving them weak and liable to fracture at the smallest stress.
– Bone mass reduces by 2.5% per year for several years
– Reduced oestrogen enhances osteoclast ability to absorb bone
– Osteoporosis
– Can be limited by oestrogen therapy

Question 15

What changes occur in the CVS

Answer 15

• Cardiovascular disease should be an elderly woman’s major concern

– The lack of oestrogen and progesterone causes many changes in women’s physiology that affect their health and well-being .
– changes in the metabolism of the body.
– Increased cholesterol level in the blood: Hyperlipidemia or an increase in the level of cholesterol and lipids in the blood is common.
• gradual rise in the risk of heart disease and stroke after menopause.

Question 16

Complete the flow diagram

Answer 16

Question 17

Treatments for menopause?

Complications for HRT?

Answer 17

Non-hormonal:

– Dressing in light layers can alleviate hot flashes and night sweats; avoiding caffeine , alcohol and spicy foods can also minimize these symptoms.

– Menopause and weight gain tend to go together due to life style changes than to the hormonal changes .

– Reducing dietary fat intake and regular exercise help to combat weight gain during menopause.

Hormonal Replacement therapy:

• overcome the short-term and long- term consequences of oestrogen deficiency.

• HRT can be administered orally
– ( in pill form),
– vaginally( as a cream),
– Transdermally (in patch form)

• before during and after menopause

• Can improve well-being
• Can limit osteoporosis
– Current advice no longer recommended for first line protection

• Not advised for cardioprotection

Oestradiol: e.g. valerate, enanthate, micronised oestradiol, ethinyl estradiol, etc. (1-2 mg/day)

Medroxyprogesterone acetate (Provera®) (2.5 mg/day) Norethisterone (1 mg/day) Levonorgestrel (1.5 mg/day)

Question 18

What is the function of the pelvic floor

Answer 18

Question 19

Support – 3 levels:

Answer 19

Suspension – vertical support working against gravity (strength required)

▪ Cardinal ligament – holding the cervix and upper vagina in place and uterosacral ligaments – holding the back of the cervix and upper vagina laterally and with the round ligament, maintain the anteverted position of the uterus

Attachment – provided by the arcus tendinosus fascia pelvis (ATFP) – white line

▪ Endopelvic fascia – from the white line over the obturator internus muscle laterally, to the vaginal wall medially

▪ Important in maintaining urinary continence as the urethra lies anterior and above it so gets compressed against it during increased intra-abdominal pressure

▪ Weakness -> stress incontinence of urine

Fusion – implies link, connection and inseparable

▪ Involves the urogenital diaphragm and the perineal body

▪ Lower half of the vagina is supported by fusion of the vaginal endopelvic fascia to the perineal body posteriorly, the levator ani laterally and the urethra anteriorly

Question 20

What makes up the pelvic floor?

Answer 20

1. Levator ani: pubococcygeus; puborectalis and iliococcygeus
2. Urogenital diaphragm/perineal membrane: deep transverse perineal & EUS
3. Perineal body: figure of 8 between uterus and anus
4. Perineal muscles: superficial transverse perineal, ischiocavernosus, bulbospongiosus
5. Posterior compartment
6. Blood supply = internal and external pudendal arteries and drains through the corresponding veins
7. Lymphatic drainage = inguinal glands
8. Nerve supply: branches of the pudendal nerve, which derives it fibres from the ventral branches of the 2nd, 3rdand 4th sacral nerve

levator ani originate: pubic bone, the white line over the obturator internus muscle and the medial aspect of the ischial spines.

Inserted: as they encircle the urethra, some are inserted as they encircle the vagina, where they take part in forming the perineal body, encircle the rectum and lower part of the coccyx and anococcygeal raphe

Question 21

Perineal Body: location and function

urogenital diaphragm origin and insertion

Answer 21

1. • Occupies a central position (and role) on the pelvic floor, between the vagina and rectum
     - Provide a point of insertion of the levator ani muscles
     - Attached posteriorly to the external anal sphincter (EAS) and the coccyx
     - Support of the perineal structures rely on it
2. • triangular sheet of dense fibrous tissue
     - Spans the anterior half of the pelvic outlet
     - Arises from the inferior ischiopubic ramus
     - Attaches medially to the urethra, vagina and perineal body
     - Thereby supporting the pelvic floor

Question 22

State some dysfunctions that can occur of the pelvic floor:

Answer 22

o Pelvic organ prolapse (POP)

o Incontinence – urinary

o Posterior compartment pelvic floor dysfunction

o Other:

• Obstetric trauma including episiotomy
• FGM
• Vaginismus
• Vulval pain syndromes

Question 23

POP

1. What is it?
2. Results in?
3. Common or not?
4. Classification of POP: (4)

Answer 23

1. Loss of support for the uterus, bladder, colon or rectum, leading to prolapse of one or more of these organs into the vagina
2. o Although non life threatening, has a significant impact on the quality of life

o Can affect perception of body image and can cause depressive symptoms

o More than anatomical defect -> can lead to infection

o anorectal, urinary and sexual function dysfunction

3. Common, up to 40% of women experiencing a degree of pelvic organ prolapse in their lifetime
4. o Anterior compartment – cystocoele, urethrocoele or cystourethrocele (bladder)

o Middle compartment (vaginal apex) – uterine prolapse – COWBOY GAIT

o Posterior compartment:

Rectocele – prolapse of rectum into posterior part of vagina

Enterocele – prolapse containing loops of bowel in the rectovaginal space (Pouch of Douglas)

o Post-hysterectomy vault prolapse – apex may prolapse producing post-hysterectomy vaginal vault prolapse, or prolapse of the vaginal cuff

Question 24

1. Risk factors:
2. What system do we use to class prolapses?
3. Factors that need to be considered when making a management plan?
4. Treatment for prolapse

Answer 24

1. o Age

o Parity

o Vaginal delivery

▪ 4x increased risk after 1st child -> 11x increased risk after 4 or more deliveries

o Postmenopausal oestrogen deficiency

o Obesity and causes of chronic raised intra-abdominal pressure

o Neurological – e.g. spina bifida, muscular dystrophy

o Genetic connective tissue disorder – e.g. Marfan’s, Ehlers-Danlos

2. POP - Q
3.  nature of symptoms and degree of bother
    nature and extent of prolapse
    completion of family and future pregnancy plans

 sexual activity
 fitness for surgery and anaesthesia
 associated incontinence symptoms
 woman’s goals

 work, physical activity and domestic circumstances
 previous management and outcome
 surgical experience and familiarity with different surgical procedures
 having realistic expectations about outcomes, in the light of history and examination.

Question 25

1. What is an episiotomy? 2. When, how to perform? 3. Complications

Answer 25

1. surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues 2. instrumental deliveries prevent obstetric anal sphincter injuries 45–60° from the midline 3.  haemorrhage  extension to the anal sphincters  infection  perineal pain  dyspareunia  cosmetic disfigurement due to poor alignment during suturing

Question 26

1. Urinary incontinence Type that occurs with dysfunction of the pelvic floor? 2. Management?

Answer 26

1. o Mainly – stress incontinence, affected by dysfunction of the pelvic floor o Other types of incontinence – urge incontinence due to overactive bladder 2. – pelvic floor exercise/ kegel - bulking agents - surgical - sling TVT

Question 27

How to manage POP

Answer 27

Question 28

Female genital mutilation 1. What is it? 2. Reasons: 3. Consequences – acute 4. Consequences – late

Answer 28

1. **partial or total removal of the external female genitalia** or other injury to the female genital organs, whether for **cultural or other non-therapeutic** reasons 2. ▪ Mistaken as a **religious practice**, a form of circumsions ▪ **Culture – purification** ▪ **Rite of passage – attainment of womanhood** ▪ Social acceptance, family honour – especially for marriage ▪ Fear of social exclusion ▪ Maintenance of chastitiy ▪ Custom or tradition ▪ Increasing sexual pleasure for male ▪ Hygiene and cleanliness 3. ▪ **Haemorrhage** – severe can lead to shock ▪ **Severe pain** – no anaesthesia ▪ **Sepsis** – severe infection ▪ Tetanus ▪ Acute urinary retention ▪ Hepatitis ▪ HIV ▪ Death 4. ▪ Sexual difficulties – fertility issues, relationship issues, rape – vicious cycle ▪ Chronic pain ▪ Keloid scar formation ▪ Dysmenorrhoea ▪ Urinary outflow obstruction ▪ Labial fusion ▪ Difficult cytological screening ▪ Difficult conceiving

Question 29

1. Obstetric and neonatal consequences o In woman who have had mutilation types 3 and 4, there is marked narrowing and scarring of the introitus and such a high incidence of tearing that an anterior episiotomy should be performed electively o FGM is illegal in the UK ▪ Once defibulation is performed, especially following delivery – must not be refibulated ▪ Safeguarding and medicolegal implications ▪ Report \<18 (child protection)

Question 30

1. Posterior compartment pelvic floor dysfunction presents as: 2. Causes?

Answer 30

1. - a **vaginal or a rectal bulge**/lump - **constipation** - **incomplete evacuation** - dyssynergic defecation (anismus) - no relaxation of the pelvic floor muscles no defecation - anal incontinence 2. **Structural,eg Rectocele,rectalprolapse**  **Drugs** eg. Opiates, Ferrous supplements  Dehydration  Immobility  **Pregnancy**  Postoperative pain

Question 31

1. Faecal incontinence is defined as the involuntary loss of ? 2. Anal incontinence is defined as involuntary loss of ? 3. Problems 4. Cause? 5. What muscles work together to prevent fecal incontinence?

Answer 31

1. liquid or solid stools that is a social or hygienic problem. 2. Latus , liquid or solid stools that are a social or hygienic problem. 3. physical and psychological distress 4. obstetric anal sphincter injury? 5. IAS, EAS, pelvic floor: puborectalis,pubococcygeas

Question 32

What is the physiology for defecation?

Answer 32

Question 33

What nerves are used in defeacation

Answer 33