Week 10 Menopause and Pelvic Floor Dysfunction Flashcards
1
Q
Definition
Menopause
A
Permanent cessation of menses after 1 year of amenorrhea
2
Q
Menopause symptoms
A
- Bloating
- Irritability
- Mastalgia
- Heavy menstrual bleeding
- Vasomotor symptoms (hot flashes)
- Insomnia
- Migraines
- PMS (premenstrual syndrome)
- Vaginal dryness or discomfort
3
Q
Classic symptom of menopause?
When most severe?
A
Hot flashes
Most severe in 1st 2 years (perimenopausal) → dramatic change
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
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
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
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
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
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
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
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.
12
Q
Genitourinary syndrome of menopause (GSM)
A
Atrophic vaginitis
With time often worsens
Decreased estrogenation → thinning of epithelial layers leading to symptoms
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
14
Q
Physical Exam appearance of GSM
A
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
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
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
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)
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
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
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
Urge urinary incontinence
Complaint of involuntary leakage accompanied by or immediately preceded by urgency
26
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!
27
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
28
Medications that can affect lower UT function
29
Functional Incontinence
* Impairment of physical or cognitive function
* Overactive bladder relative to access
* Secondary gain
30
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
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
OAB advanced tx
Botox - decrease spasms
Peripheral afferent nerve stimulation
Sacral Nerve stimulation
Surgery options: slings and injections
39
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)
40
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”
41
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?
42
Rectal Prolapse
First line tx: FIBER
FiberCon
Citrucel
Benefiber
Metamucil
43
Pharm tx for rectal prolapse
Antidiarrheals: Imodium, Lomotil
Cholestyramine
Probiotics
Tincture of opiate
TCAs
44
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
45
Diagnostics Fecal Incontinence
o Anorectal manometry
o Pudenal Nerve Terminal Notor Latencies
o Endoanal U/S: Visualize integrity of Spincter complex
46
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
47
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
48
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
49
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
50
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
51
Management of prolapse
o Serial Observation
o Vaginal pessary
o Surgery
52
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)
