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