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GYNECOLOGIC ISSUES
IN THE LATE POST MENOPAUSAL WOMAN
Elaine E. Jolly, O.C., M.D., F.R.C.S.(C.)
Medical Director
Shirley E. Greenberg Women’s Health Centre
Professor of Obstetrics and Gynaecology
University of Ottawa
GYNECOLOGIC ISSUES
in the “Geripause”
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Introduction
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Life Threatening Disorders: Cancers
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Most Common Gynecologic problems
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Summary
Physiology of the “Geripause”
Decreased Estrogen Causes Progressive Atrophy
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Thinning of vulvar tissue
Thinning, greying, loss of pubic hair
Diminution of labia minora
Presence of petechia
Vaginal walls are atrophic and pale
Shortening and narrowing of vagina
Atrophy of cervix / cervical stenosis
Decreased uterine size
Atrophic endometrium
Fibrous myometrium
Ovarian senescense
Gynecologic Examination in the
Elderly Female
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Abdominal/inguinal exam
Vulvar/perineal inspection
Inspection of Vagina/Vault
Cervix (stenosis), Pap Smear (brush)
Bimanual exam (uterus/adnexa)
Pelvirectal exam
Gently, slowly, sensitively
Be innovative and accommodating
Respect patient’s modesty
Warm hands – warm instruments
Gynecologic Issues
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Life Threatening Disorders
Quality of Life Issues
Life Threatening Disorders
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Ovarian Cancer
Uterine Cancer
Cervical Cancer
Vulvar Cancer
Incidence of Cancer in Women
136,000
76,000
52,000
50,000
34,000
18,000
Breast
Colon &
Rectum
Lung
Endometrium
Ovary
12,900
Cervix
CIN
Ref: 1988 Annual Rate Estimates Based on NGI SEER Programme 1982-1984
Causes of Cancer Death
in Women
46,000
42,000
31,900
12,000
8,000
3,000
Lung
Breast
Colon &
Rectal
Ovary
Cervix
Endometrim
Ref: 1988 Annual Rate Estimates Based on NGI SEER Programme 1982-1984
Ovarian Cancer
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Lifetime Risk 1/70
2% of Deaths over age 40
Difficult/delayed diagnosis
5 year survival, all stages 35-38%
2/3 of women diagnosed at Stage 3 or 4
Ovarian Cancer: Risk Factors
Risks
R.R.
Lifetime
Risk
No Risk
1.0
1.2
Familial CA Syndrome
Unknown
up to 50
One 1st/2nd0 Relative
3.1
3.7
2 or 3 Relatives
4.6
5.5
Oral Contraceptive Use
0.65
0.8
Pregnancy
0.5
0.6
Ref: Carlson et al. Ann Int. Med. 1994, 121:126
Ovarian Cancer
Diagnosis: Screening
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Routine Exam
- inadequate sensitivity/specificity
18,000 exams in 1,319 women 6 cancers
all widely disseminated
- transvaginal ultrasound (TVU)
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CA 125
Doppler blood flow
Genetic markers
- Hereditary Cancer Syndromes 0.05%
Endometrial Carcinoma
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Most common gynecologic cancer
80% post menopausal (age 55 to 69)
90% patients present with BLEEDING
Endometrial biopsy: Diagnosis
Thickened endometrial echo on
vaginal ultrasound
Stage 1 disease 75 to 97% survival
Endometrial Cancer: Risk Factors
RISK FACTOR
Oligomenorrhea
Obesity
Diabetes
Hypertension
Polycystic Ovarian Disease
CA of Ovary
CA of Breast
CA of Colon/Rectum
n
%
382
2971
1746
3048
80
90
211
88
5.5
43.0
24.0
44.1
1.2
1.3
3.1
2.0
Ref: Wharton J.T. Surg. Gynecol. 1986, 162-515
Endometrial Cancer
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Unopposed ERT
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Tamoxifen Rx
“Endometrial Surveillance”
Endometrial Surveillance
1964
1. Cytology (Pap Smear)
2. Endometrial Biopsy
3. D & C (Dilation & Currettage)
2007
1.
2.
3.
4.
5.
Endometrial Biopsy / D & C
Vaginal Ultrasound
Doppler blood flow (TVU)
SIS (Saline Infused Sonohysterography)
Hysteroscopy / D & C
Office Endometrial Biopsy
Assessing Endometrial Thickness
with Vaginal USS
Cervical Intraepithelial Cancer
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Steady decline in incidence
70% decrease in death rate over 40 yrs.
PAPANICOLAOU SMEAR
Preinvasive → Invasive CA 20 years
Related to sexual activity
Related to Herpes Simplex type 2
HPV types 16 and 18
Cervical Cancer: Risk Factors
Risk Ratio
Age at first intercourse (<17)
Number of sexual partners (>6)
High risk male partner
Herpes Simplex II
HPV
Cigarette Smoking
1.9
2.8
2.7
2.8
3.0
4.0
to 5
to 6
to 6.8
to > 10
to >10
Cervical Cancer: Older Women
Age 65 + Annual death rate 159 per million
Age 35 + Annual death rate 44 per million
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More than ½ of women with invasive cervical cancer have
NOT had a pap within 3 years.
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Unscreened women are older, less sexually active, less
well-educated and their cancers are more advanced.
Ref: Clinics in Geriatric Medicine: G.U. problems 1998; 306-12
Cancer of the Vulva
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5% gynecologic cancers
65% 5 year survival
Readily accessible on examination
Delay in diagnosis/biopsy
Amenable to Surgical Rx
Associated with:
- obesity
- chronic irritation
- vulvar dystrophy
- diabetes
Cancer of the Vulva
Look! - Biopsy!
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Treatment: Surgical Excision
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Prognosis:
Good if lesion < 2 cm
Poor if lesion > 2 cm + nodes
Screening for Malignancy: Factors
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Incidence and natural history of cancer
Age related changes in test sensitivity & specificity
Ability to influence the course of disease
Risks of death/disability from other health problems.
Barriers to screening
Patient preferences and values
Estimated life expectancies
Age 78 – women have 10 more years
Age 89 – women have 5 more years
Comorbidities affect these estimates
The Aging Woman
Most Common Gynecologic Problems:
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Vulvar vaginal
Genital prolapse
Alterations in bladder function
Post menopausal bleeding
“Geripause”
Ref: Gyne assessment of the Elderly Patient - Mark Williams, April 2007, MEDSCAPE Review
Vulvar Vaginal Problems
in the Aging Women
Vulvar/Vaginal Conditions
in the Elderly
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Vulvar skin conditions
Pruritus
Burning and Irritation
Vulvar swelling
Vulvar Conditions in the Elderly
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Skin changes – seborrheic keratosis
– skin tags
Fissures
Ulcerations
Hypertrophic or verrucous lesions
R/
O
MALIGNANCY
Vulvar Pruritus in the Elderly
R/O MALIGNANCY
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Estrogen Deficiency
Lichen Sclerosis (LS&A)
Candida Infection
 Diabetes
 Antibiotics
 Corticosteroids
 Immunosuppression
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Pernicious Anemia
Liver Disease
Diabetes Mellitus
Lymphoma
Leukemia
Vulvar Burning in the Elderly
R/O MALIGNANCY
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Vulvovaginal Atrophy
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Candida Infection
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Paget’s Disease of the Vulva
Adenocarcinoma in Situ
PAGET’S DISEASE OF THE VULVA
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Velvety red or eczematous appearance
When a yeast infection does not clear up
Colposcopy of the Vulva
- Biopsy reddened/affected areas
Associated with 30% coexistent cancer
Search for “occult malignancy”
Breast, Cervix, Bladder,
Gall Bladder, Colon
Vulvovaginal Discharge in the Elderly
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Atrophic Vaginitis
Often misdiagnosed as a yeast infection
- no odour
- bacteria minimal
- responds to local estrogen
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Bacterial Vaginosis “malodorous & abundant”
Candida – white, flocculent, itchy
Trichomoniasis
– malodorous,
– yellow-green & itchy
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Quality of Life: Atrophic Vaginitis
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Decreased Vaginal mucosal thickness
Decreased Vaginal acidity
Decreased Vaginal secretions
Pain, irritation, infection
Dyspareunia
Decreased sexuality
RELIABLY REVERSED BY ESTROGEN
Sexuality in the Mature Woman
Estrogen
Deficiency
Sexual
Changes
Mental and
Physical Health
Quality of Life: Urothelial Atrophy
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Estrogen Deficiency
Atrophy urethral mucosa, bladder
Frequency, urgency, nocturia
Urinary incontinence
Recurrent Cystitis
REVERSED BY ESTROGEN
Vulvar Swelling in the Elderly
BIOPSY - R/O Malignancy
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Urethral caruncle – common
Extrogen RX - If no response in 6 wk biopsy
Vulvar lesions – white-brown-red-raised - ulcerated
Swelling in Posterior Vulva
– Adenocarcinoma is aggressive here
Swelling of Anterior Vulva
– most common site of invasive cancer
– around the clitoris, vestibule or labia
– flat infiltrative or ulcerative lesion
Basal Cell Cancer
– pearly appearance with telangiactasia
The Aging Woman
Genital Prolapse
or
Pelvic Organ Prolapse (POP)
Prevalence
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POP > 50% of women over 50.
Life time prevalence of 30-50%.1
Women > 65 are the fastest growing segment of the
population.
Demand for services expected to double in the next
30 years.2
1-Subak LL et.al Obstet Gynecol 2001;98:646-51
2-Luber KM et.al. Am J Obstet Gynecol 2001;184:1469-1501
Clinical Classification of Pelvic
Organ Prolapse
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Anterior Vaginal Wall
– Cystocele
– Cystourethrocele
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Apical Vaginal Wall
– Uterovaginal
– Vaginal vault (after hysterectomy)
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Posterior Vaginal Wall
– Enterocele
– Rectocele
Prolapse
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Cystocele
Descent of anterior vaginal wall
and overlying bladder base
Rectocele
herniation and bulging of
posterior vaginal wall and
underlying rectum into
vaginal lumen
Enterocele
herniation of peritoneum
(+/- intraperitoneal contents)
in areas of pelvic floor
Uterine / Vaginal Vault Prolapse
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First degree/grade
prolapse
– mild degree of
prolapse of upper
vagina and cervix;
– descent halfway
to the hymen
Uterine / Vaginal Vault Prolapse
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Second Degree
Prolapse
– cervix or vaginal
apex extends to
the hymen
Uterine Prolapse
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Third Degree
Prolapse
– cervix or corpus
uteri extend
outside of hymen
– or vaginal vault is
everted
Treatment options
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Expectant management.
Pelvic floor exercises.
- Kegels, vaginal cones, biofeedback
- Electrical stimulation of pelvic floor
Mechanical supportive devices: Pessary
Surgery
Progression of prolapse
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Handa and Jones ’03:
– 56 women fitted with pessary
– 19 followed over 1 year
– No women had worsening in stage of prolapse.
– Four women had improvement.
Complications of Pessaries
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Most common problems involve vaginal discharge
(leukorrhea) and vaginitis.
Vaginal erosions especially with the cube pessary
Ulceration
Incarceration
Urosepsis
Fistula formation
Surgery for Pelvic Organ Prolapse
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An elective procedure
Medically indicated if:
‒ Urinary retention
‒ Hydronephrosis/renal failure
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Complications of surgery:
‒ Urinary incontinence
‒ Dyspareunia
‒ Recurrence
Vaginal vs Abdominal
Procedures
Evidence from randomized trials has
demonstrated that abdominal repairs
are more durable and offer anatomically
superior results, while vaginal repairs
have fewer complications, including
foreign body complications.
Vault Prolapse
Vault prolapse occurs
after 1/200 (0.5%)
hysterectomies
Laparoscopic Surgery
for Repair of Pelvic Floor Defects
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short hospital stay
decreased pain
smaller scar
faster post-op recovery
improved visualization of the surgical field
accuracy of suture placement
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possibly improve long-term outcome.
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The Aging Woman
Alterations in Bladder Function
Prevalence of Urinary
Incontinence
Population Subgroups
Prevalence
(%)
Nursing Home Residents (>65 years)
50
Homebound Elderly Persons (>65 years)
Hospitalized Elderly Persons (>65 years)
50
25-30
Adult (age 15-64 years)
10-70
Implications of Incontinence
Morbidity
Medical:
Decubitus ulcer
Skin rashes
UTI, Urosepsis
Falls
Social:
Loss of self-esteem
Social restriction
Depression
Economic:
Personal costs
Societal costs
Economic Implications
of Incontinence
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Personal:
– Containment devices
– Medication
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Societal:
– Direct costs for incontinence care in US $12.43 billion
(2001) nursing facilities
– Leading cause of institutionalization in US
– Leading cost to Medicare for home care in US
Treatment Options
Vaginal Atrophy
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estrogen
polycarbophil gel
regular coitus
Recurrent UTI
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estrogen
antibiotics
cranberry juice
Incontinence
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estrogen
pelvic floor muscle
retraining
pessaries
surgery
antimuscarininc Rx
bladder drill
Kegel Exercises
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10 – 20 repetitions three times per day
Hold contraction for 5 to 10 seconds
A set can be done to suppress urgency
Results take 6 – 8 weeks to manifest
NOT done while voiding
Improvement & cure rates as high as 80%
BLADDER DRILL
Retro Pubic Urethropexy
Major Surgery
Tension Free Vaginal Tape
Day Care Surgery
TVT
Advantages of TVT
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Out Patient procedure
Short OR time
May be performed under local anesthesia
Tape is loosely placed (tension free)
minimizing anatomic distortion
Decreased incidence of post–op voiding
dysfunction
TVT results at 7 yrs
Observational prospective study
on 90 women
Cured
81.3%
Negative stress test
Negative 24h pad weighing test
Improved
16.3%
Failed
2.5%
Ref: Nilsson CG, Obstet Gynecol 2004
The Aging Woman
Post Menopausal Bleeding
Post Menopausal Bleeding:
Causes
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Vaginal
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Uterine
- Atrophic Vaginitis
- Trauma
- Malignancy
- Hormone RX
- Unopposed Estrogen
- Continuous Combined E + P
- Insufficient Progesterone
- Tamoxifen
- Endometrial Polyp
- Endometrial Cancer
Post Menopausal Bleeding:
Causes (2)
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Ovarian
- Malignancy
- Benign Tumour
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Fallopian tube
- Malignancy
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Vulvar Neoplasia
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Urinary Tract
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G.I. Tract
- Infection/stone
- Bladder cancer
- Colorectal cancer
SUMMARY
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In 2005 Cdn Census – 5.5 million women aged 50+
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By 2026 women 50+ will represent 22% of pop.
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Health promotion, disease prevention,
early diagnosis, state of the art treatments
and promoting quality of life is vital
for geriatric health
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It is imperative that all aging women have appropriate
Gynaecological assessment,
treatment and follow-up.
Otherwise…