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33 Cards in this Set
- Front
- Back
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Reproduction System- Menopause by Aliff
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Reproduction System- Menopause by Aliff
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Define menopause, and ages, smoking related to menopause.
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-Cessation of menses for one year is true menopause
-Perimenopause is the period immediately before and after the menopause -Climacteric encompasses both phases -The mean age is 51-52 years old -Median age of onset at perimenopause is 47.5 years and lasts about 4 years -10% of women skip perimenopause and rapidly cease cycling -Smoking decreases the age of menopause by 2 years |
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Symptoms and physical alterations
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-Disturbance on the menstrual pattern
-Vasomotor instability-”hot flashes” -Atrophy- dyspareunia, pruritis, urinary difficulties and incontinence -Psychological issues-anxiety, depression, insomnia, decreased libido -Body Mass-body weight and total body fat increase after menopause -Skin-decreased collagen leading to thinning and wrinkling -Genitourinary Tract- decreased collagen in the uterosacral and cardinal l-ligaments leading to pelvic organ prolapse |
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Osteoporosis
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Osteoporosis-
Presence usually detected after a fracture Bone loss at a rate of 1-2%/year the first few years after menopause then slows down Loss occurs more rapidly in trabecular bone than cortical bone Bone resorption increases while rate of formation is unchanged |
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When do you do screenings?
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Mammography-yearly after 40 yo
Lipid profile-every 5 years at 45 yo Fasting blood glucose-every 3 years at 45 TSH- every 5 years after 45 Colorectal screening yearly after 50 Cervical cancer screening- yearly to every 2-3 years |
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Bone density screening
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Bone density screening
Typically Dual-energy X-ray absorptiomerty (DEXA) Begin at age 65 for women with no risk factors Age 60 for those with risk factors OR any post-menopausal woman with one or more risk factors (The National Osteoporosis Foundation) |
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Risk Factors
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White or Asian race
Cigarette smoking Menopause Low-low normal BMI Alcohol use Chronic illness Diet poor in calcium /vitamin D |
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DEXA scans... T and Z score and wht it means
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Measured at the spine and femoral neck
T score-difference between the BMD of the test subject and the mean BMD divided by the standard deviation of the mean of young normal adults of the same gender Z score-age and gender matched controls Osteopenia- T score between -1 and -2.5 Osteoporosis- T score less than -2.5 |
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Treatments...rhymes with bestrogen and brogesterone
what MUST you do. |
Estrogen:
Body Mass- shown to decrease wt gain and the propencity for abdominal fat Skin-prevents the loss of collagen GU-prevents collagen loss and treats atrophy Hot Flashes/Flushes-stabilizes estrogen levels Osteoporosis-hypothesized inhibition of parathyroid hormone Progesterone: Necessary to prevent endometrial hyperplasia in women with a uterus Cycling hormones can cause “periods” Continuous therapy an option ***MUST GIVE PROGESTERONE TO ANY WOMAN WITH A UTERUS IF YOU PUT HER ON ESTROGEN***** -need to shed that lining to prevent endometrial cancer. |
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The Women's Health Initiative involved 161,808 women who were are all ____-____, ages 50-79, and tested the effects of HRT, diet, Ca2+, vit d on heart disease, fractures, breast and colorectal cancer
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post-menopausal
Hormone trial Two arms: Estrogen + Progesterone arm for women with a uterus Estrogen only for those without a uterus |
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Of 10,000 post-menopausal women
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8 more will have invasive breast cancer
7 more will have MI 8 more will have CVA 18 more will have blood clots all in women over 65 |
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The Women’s Health Initiative newest findings
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Newest Findings
Coronary Artery Calcium lower in women aged 50-59 on estrogen Breast cancer-decreased risk in women already at low risk-converse is also true VTE- increased risk of 0.22-0.30 per woman per year CNN sucks. |
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Bioidentical Hormones
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What does this mean?
What are the risks? Salivary vs blood levels. specific amounts of estro/progest per person. tailored to the pt. may be different amounts of hormone per pill...tough to follow no safer than anything else. no black box warnings. replacement of testosterone...weight gain, decreased libido w/o it, so when you get it, these aren't an issue, but can increase risk for breast cancer. |
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OBJECTIVES:
Define the different types of pelvic floor prolapse Enumerate the risk factors Identify basic pelvic anatomy Understand treatments available Understand work-up and treatment of urinary incontinence |
Define the different types of pelvic floor prolapse
Enumerate the risk factors Identify basic pelvic anatomy Understand treatments available Understand work-up and treatment of urinary incontinence |
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Risk Factors
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-Multiparity
-Advanced age -Estrogen deficiency -Obesity -Neurogenic dysfunction of the pelvic floor -Connective tissue disorders -Chronically increased intra-abdominal pressure |
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CYSTOCELE: downward displacement of the bladder
CYSTOURETHROCELE: cystocele that includes the urethra UTERINE PROLAPSE: descent of the uterus and cervix into the vaginal canal toward the vaginal introitus RECTOCELE: protrusion of the rectum into the posterior vaginal lumen ENTEROCELE: herniation of the small bowel into the vaginal lumen |
CYSTOCELE: downward displacement of the bladder
CYSTOURETHROCELE: cystocele that includes the urethra UTERINE PROLAPSE: descent of the uterus and cervix into the vaginal canal toward the vaginal introitus RECTOCELE: protrusion of the rectum into the posterior vaginal lumen ENTEROCELE: herniation of the small bowel into the vaginal lumen |
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Pelvic support anatomy, name 4
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UTEROSACRAL
CARDINAL LIGAMENT LEVATOR ANI MUSCLES ENDOPELVIC FASCIA levator muscles: iliococcygeus, pubococcygeus, puborectalis |
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Clinical Manifestations and urinary complaints.
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-Asymptomatic
-No clear relationship with location of prolapse and dysfunction -Feeling of pressure (most common) similar to sitting on an egg or low backache heaviness that worsens as the day progresses Urinary complaints: Stress incontinence Frequency Urgency/ urge incontinence Hesitancy / weak or prolonged stream Incomplete voiding Need to reduce prolapse or change position to initiate voiding (SPLINTING) |
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Types of prolapses and their symptoms.
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Specific types of prolapse may be associated with specific symptoms
Anterior: hypermobile bladder neck with urinary stress incontinence Large Anterior: vaginal vault eversion with urinary retention Posterior: rectocele can cause obstipation Sexual impairment with any compartment |
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Bowel Symptoms and sexual symptoms
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Difficulty/ discomfort
Incontinence of flatus/ stool Urgency Incomplete emptying Rectal protrusion during or after defecation Need to reduce prolapse to defecate Pain Change in orgasmic response Incontinence |
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What's the most important part of the diagnostic evaluation?
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standing exam.
Pelvic Exam: stand on floor with one foot elevated perform rectovaginal exam with vasalva. Supine use Sims speculum. QTip test for stress incontinence |
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Enterocele
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A herniation of bowel and the lining of the peritoneal cavity through the cul-de-sac of Douglas.
Embryologic factors: congenitally deep cul-de-sac serves as a wedge for small bowel to dissect down. May cause vaginal vault eversion |
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Types of enterocele
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Types:
1. Congenital: Posterior to vaginal vault. mostly without vault eversion 2. Pulsion: Due to cervical prolapse which brings the anterior margin of the cul-de-sac down 3. Traction: Prolapsed organs exert tension on vaginal vault. Preceded by cystocele and rectocele 4. Iatrogenic: Surgically induced |
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Clinical manifestations
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Clinical Manifestations:
1) Pelvic heaviness and bearing down feeling especially when standing (due to the pull of gravity which stretches the mesentery) 2) Backache (involvement of the cardinal and uterosacral ligaments) 3) Dyspareunia Clinical Manifestations (continued): Vaginal dryness Ulceration, bleeding Bowel difficulty 7) Post-evacuation discomfort |
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tx
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PROPHYLAXIS: decrease intra-abdominal pressure (obesity, girdles, smoking)
MEDICAL: PESSARIES RING DOUGHNUT GELLHORN (didnt get into these) MEDICAL: Estrogen cream Isometric exercises (Kegel’s)-- for early prolapse. |
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Enterocele: Surgery indications and choice of procedure
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INDICATIONS: pain, ulceration, urethral or ureteral obstruction
CHOICE OF PROCEDURE: Skill of surgeon No gold standard Transvaginal or Abdominal approach Cure rate: 80-100% Recurrence rate: <10% |
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Whoa so what is a uterine prolapse? what is it usually due to? clinical manifestations?
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Descent of the uterus and cervix down the vaginal canal toward the introitus
Usually due to injury to the endopelvic fascia (cardinal/ utersacral ligaments) and relaxation of the musculature of the pelvic floor (levator ani) Post menopause, multipara, loss of estrogen, repetitive increase in intra-abdominal pressure (smoker) CLINICAL MANIFESTATIONS: Same as enterocele plus…. Sitting on a lump More urinary symptoms Symptom relief from lying down |
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tx of prolapse
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PESSARY: for poor surgical candidates
KEGEL’S: little value VAGINAL ESTROGEN: improves tissue quality |
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Surgical options for prolapse...what is the gold standard?
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Colporrhaphy: Traditionally high failure rates >50%
Mesh augmentation: No long term trials. Worry about mesh complications. Suspension: Sacrospinous ligament fixation vs. Abdominal Sacrocolpopexy (gold standard now being done with robotics!!) |
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Stress Urinary Incontinence
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Loss of urine during activities resulting in increased intra-abdominal pressure.
Abdominal pressure overcomes urethral closure pressure. Most commonly associated with urethral hypermobility due to prior birth injury. ANATOMICAL -usually due to child birth, poor tissue quality. |
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Dx
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Intake and voiding diary.
Pelvic exam with Q-tip test. Urine analysis and culture. Simple office cystometrics. Video Urodynamics |
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Nonsurgical tx
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Intake restriction and timed voiding.
Kegel’s exercises if mild. Pessary with incontinence ring. |
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Surgical Tx...what's the gold standard?
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Surgical:
Burch: Gold standard. Invasive via abdominal approach. Tension free vaginal tape. Less invasive suprapubic approach. Transobturator midurethral sling. Less invasive. Single incision slings: Newest least invasive. |
