Menopause
P to decrease CA risk
HRT- if you have uterus what must be added
0 no prolapse 1 most dital prolapse > 1cm above hymen 2 most dital prolapse 1 cm above and 1 cm below hymen 3 most dital prolapse > 1 cm below hymen but 2 cm shorter than entire vaginal length 4 complete procidentia
POP-Q stages 0-4
apex of vagina sewn to fascia of other structure (Fascia from thigh) other end attached to periosteum of sacrum
abdominal sacral colpopexy
breast or EM CA pregnant undiagnosed vaginal bleeding cardiac disease liver disease thromboemobolic disease
absolute contraindications to hrt
complete needs prior hysterectomy lefort requires dilation and curretage or em bx prior to surgery and need lateral channels to drain
complete vs lefort copoclesis
EM hyperplasia VTE osteopenia and osteoporosis
compunded bioidential hrt increases risk for (3)
c: herniation of anterior vaginal wall due to damage of pubocervical fascia; often due to trauma at childbirth, sense of something falling out, dificulty with urination R: defect of retrovaginal spetum, usually during trauma to pineal body during childbirth. constipation, heavy feeling
cystocele vs rectocele
can taper or stop may need to continue over 65
duration of HRT
kinda unknown involves E, FSH, HPA obesity is risk factor due to insulation frm adipose tissue high soy may decrease invidence
etiology of vasmotor symptoms (hot flashes)
colpesis either complete or lefort
for pts who cannot tolerate major surgery
hysterectomy w/ abdominal sacral copopexy or sacrospinous ligament fixation
for pts who cna tolerate major surgery...
get FSH levels in menopause > 30
how do you dx menopause if pt had hysterecomy or is under 40
estrogen may increase VTE by hepatic induction of factor 7, 8c, protein C and CRP transdermal E avoids first pass and may supress plasminogen
how does hrt increase VTE, how do you avoid
no
if using topical E do you need to add P?
uterine prolapse in pts who do not want vaginal penetration
indication for LeFort colpocleisis
recurrent cystocele or vaginal vault prolapse
indication for abdominal sacral colpopexy
uterine prolapse in pts who do not want vaginal penetration
indication for posterior vaginal repair
can be performed at time of hysterectomy with symptomatic vaginal vault prolapse
indication for uterosacral ligament fixation
can be performed at time of hysterectomy with symptomatic vaginal vault prolapse
indivation for sacrospinous ligament fixation
kegels Pessaries w/ estrogen cream
management
no menses x 12 mos due to ovarian failure
menopause def
SERMs (raloxifene and tamoxifen or ospemifene)
non hormonal tx options for lower genital tract symptoms
paroxetine clonidine gabapentin phytoestrogens
non hormone meds
300-500 cc
normal bladder volume
osteoporosis and osteopenia due to lack of E
other effects
declining E causing high FSH and absence of ovulation failure to ovulate means no P stimulation of EM and thus no bleeding
pathophys in menopause
5-7 years prior
permenopause
smoking hyperlipidemia leimyomata uteri
relative contraindications to HRT
parity obesity advanced age chornic constipation
risk factors for pelvic organ prolapse
increasing age female local trauma (cystocele, rectocele) menopause (E receptors in urethra) neuro injury: MS, lou gherigs, neurogenic bladder, spinal cord injury
risk factors for urinary incontinence
cough stress test qtip test for urethral mobility valsalva maneuver and measure angle post void residula volume with u/s if volume < 150 cc normal bladder
specialized tests
wt loss bladder training fluid management (decr caffeine, fluids < 2L per day) kegels biofeedback
tx
meds: antimuscarininc b agonists (Mirabefron): relaxes detrouser *contra- htn, ESRD, hepatic disease* onabotulinmtoxin A
tx for urge incontinence
urethral bulking agents: collagen, pyrolytic carbon coated beads, Ca hydroxylapatite srugery if not improved- mid urethral mesh sling either retropubic or tranobturator
tx of stress incontinence
E deficiency causes tissues to become thinner and decreases secertions
vulvaginoal atrophy phathophys
40
vulvovaginal atrophy affect __% of women
metho acetate nerthindrone micronized p
what Ps can be used in HRT
urogenital distress inventory incontinence impact questionaire incotinence quality of life questionnaire
what are the 3 questionaiires
have pt keep voiding diary 3-5 days PE u/a and urine culture measure post void residual volume
work up